FINAL REPORT Baseline Survey and Establishing Benchmarks for Project

FINAL REPORT

Baseline survey and establishing benchmarks for project evaluation in selected key – MNCH indicators for UNICEF-KOICA MNCH project in 4 intervention zones Segen, Kefa and Bench Maji of SNNP and Jimma of Oromia regions

Reference number: RFP-S&L-2016-9127376 Submitted to: UNICEF Ethiopia

Submitted by:

ABH SERVICES PLC, AN AFFILIATE OF JIMMA UNIVERSITY

DUNS: 850459757

ADDRESS

Bole Road, In front of The Millennium Hall Email: [email protected] Tel.: +251116186520 Web site: www.abhethiopia.com Addis Ababa, Ethiopia

CONTACT PERSONS

Primary Contact Additional Contact Name Dr. Markos Feleke Dr. Mengistu Tafesse Title CEO Technical Director Email [email protected] [email protected] Telephone +251-911-511610 +251-911-217919 Fax +251-11-6-186528 +251-11-6-186528

July 10, 2017

Table of Contents

...... 5 List of tables ...... 9 List of figures ...... 10 Acronyms ...... 12 Executive Summary ...... 18 1. Introduction ...... 19 2. Objectives ...... 20 3 Methods ...... 20 3.1 Study area and population ...... 20 3.2 Study design and study subjects/units ...... 21 3.3 Sample size and sampling techniques ...... 22 3.4 Data collection Techniques and tools ...... 24 3.5 Data quality control ...... 24 3.6 Data management and analysis ...... 25 4 Ethical considerations 5. Results ...... 26

...... 26 5.1 Back ground characteristics of the participants of household survey

5.2 Findings related to Objective 1: Assess awareness and knowledge of mothers on high ...... 28 impact MNCH services in the project intervention areas.

5.3 Findings related to Objective 2: Determine the level of utilization and associated factors of high impact maternal health services, newborn health services (including utilization of treatment for .. 30 newborns with sepsis at community level), and child health services during the first year of life...... 30 5.3.1 Utilization of ANC services ...... 35 5.3.2 Utilization of delivery care services ...... 40 5.3.3 Utilization of PNC services ...... 42 5.3.4 Utilization of NBC services ...... 45 5.3.5 Utilization of child care services ...... 48 5.3.6 Conclusion and recommendation on utilization of MNCH services 2

’ 5.4 Findings related to Objective 3: Assess mothers perceived quality of high impact MNCH ...... 48 services in the project intervention areas. .... 48 5.4.1 Quantitative findings from household survey related to quality of MNCH services ...... 53 5.4.2 Qualitative findings related to quality of MNCH services ...... 55 5.4.3 Conclusion and recommendation on the perceived quality of MNCH services

5.5 Findings related to Objective 4: Explore the demand for high impact MNCH services - ...... 55 ANC, SBA, ICCM, CBNC, Newborn Corner, NICU, and BEmONC...... 55 5.5.1 Quantitative findings regarding the demand for MNCH services ...... 58 5.5.2 Qualitative findings regarding the demand for MNCH services ...... 58 5.5.3 Conclusion and recommendation on the demand for MNCH services

5.6 Findings related to Objective 5: Examine the actual referral linkage process and mechanisms in place for Maternal and newborn cases within the primary care units/delivery ...... 59 platform ...... 59 5.6.1 Quantitative findings related to referral linkage ...... 61 5.6.2 Qualitative findings related to referral linkage process ...... 62 5.6.3 Conclusion and recommendation on the referral linkage process

5.7 Findings related to Objectives 6,7, and 8: Availability and quality of high impact MNCH ...... 63 services, MNCH equipment, drugs and supplies...... 63 5.7.1 Results of health post (HP) assessment ...... 74 5.7.2 Results of health center (HC) assessment ...... 98 5.7.3 Results of hospital assessment

5.7.4 Conclusions and recommendation on availability and quality of high impact MNCH ...... 119 services, MNCH equipment, drugs and supplies

5.8 Findings related to Objective 9: Identify critical challenges with regard to MNCH services ...... 123 utilization both from demand and supply side ...... 123 5.8.1 Challenges of lack of awareness ...... 123 5.8.2 Challenges of accessibility of health institutions

5.8.3 Challenges of availability of MNCH services, equipments, drugs, and other supplies 124

...... 124 5.8.4 Challenges of adequacy of rooms in health institutions

...... 125 5.8.5 Challenges related to maternity waiting rooms ...... 125 5.8.6 Challenges of availability of skilled man power ...... 125 5.8.7 Challenges of staff behaviour ...... 126 5.8.8 Challenges related to culture and religion ...... 126 5.8.9 Challenges within the family ...... 126 5.8.10 Challenges related to water and electricity ...... 127 5.8.11 Challenges of communication ...... 127 5.8.12 Challenges of recording and reporting ...... 127 5.8.13 Conclusion and recommendation ...... 129 6 References

List of tables

Table 1: Background characteristics of mothers who have under-one year infant in Segen, Kefa and ...... 26 Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 2: Awareness and knowledge of mothers on MNCH services in Segen, Kefa and Bench Maji of ...... 29 SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 3: Utilization of ANC services by background characteristics in Segen, Kefa and Bench Maji of ...... 31 SNNP Region, and Jimma Zone of Oromia Region Table 4: Factors associated with ANC service utilization in Segen, Kefa and Bench Maji of SNNP ...... 32 Region, and Jimma Zone of Oromia Region, March 2017 Table 5: Sites where ANC service was provided and frequency of ANC visit in Segen, Kefa and ...... 33 Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 6: Services provided during ANC visit in Segen, Kefa and Bench Maji of SNNP Region, and ...... 34 Jimma Zone of Oromia Region, March 2017 Table 7: Utilization of health facilities during delivery by background characteristics in Segen, Kefa ...... 36 and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 8: Factors associated with skilled birth attendance in Segen, Kefa and Bench Maji of SNNP ...... 38 Region, and Jimma Zone of Oromia Region, March 2017 Table 9: Utilization of PNC services by background characteristics in Segen, Kefa and Bench Maji of ...... 40 SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 10: Type of services given to mothers during PNC visit in Segen, Kefa and Bench Maji of ...... 41 SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 11: Utilization of NBC services by background characteristics in Segen, Kefa and Bench Maji ...... 42 of SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 12: Factors associated with newborn care services utilization in Segen, Kefa and Bench Maji of ...... 44 SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 13: Newborns treated at home by HEW and health institutions when having health problem in ..... 45 Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 14: Children 2 months to less than one year treated at home by HEW and health institutions when having health problem in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of ...... 47 Oromia Region, March 2017 Table 15: Perception of mothers on the quality of MNCH services in Segen, Kefa and Bench Maji of ...... 50 SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 16: Perception of mothers on the quality of different MNCH services in Segen, Kefa and Bench ...... 52 Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 Table 17: Demand for MNCH services in Segen, Kefa and Bench Maji of SNNP Region, and Jimma ...... 57 Zone of Oromia Region, March 2017 Table 18: Referral process in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of ...... 60 Oromia Region, March 2017 Table 19: Distribution of surveyed health posts by zone and woreda in SNNP and Oromia Regions; ...... 63 UNICEF/KOICA Baseline survey, March 2017 Table 20: Facility structure and referrals the HCs, KOICA/UNICEF Baseline survey, Oromia and ...... 64 SNNP, March 2017 Table 21: Status of Services Provided to Pregnant women at HP level, KOICA/UNICEF Baseline ...... 66 survey, Oromia and SNNP, March 2017 5

Table 22: Status of iCCM services at HP level, KOICA/UNICEF Baseline survey, Oromia and SNNP, ...... 67 March 2017 Table 23: CBNC activities performed at HP level, KOICA/UNICEF Baseline survey, Oromia and ...... 68 SNNP, March 2017 Table 24: Availability of MNCH equipment and supplies at HP level, KOICA/UNICEF Baseline ...... 70 survey, Oromia and SNNP, March 2017 Table 25: Availability of UNEXPIRED drugs, stock of status and average duration at HP level, ...... 72 KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 Table 26: Availability of job aids and guidelines at HP level, KOICA/UNICEF Baseline survey, ...... 73 Oromia and SNNP, March 2017 Table 27: Availability of recording and reporting forms at HP level, KOICA/UNICEF Baseline ...... 74 survey, Oromia and SNNP, March 2017 Table 28: Distribution of surveyed health centers by zone and woreda in SNNP and Oromia Regions; ...... 75 UNICEF/KOICA Baseline survey, March 2017 Table 29: Main source of drinking water and electric power supply for the HCs, KOICA/UNICEF ...... 76 Baseline survey, Oromia and SNNP, March 2017 Table 30: ANC service availability at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, ...... 77 March 2017 Table 31: ANC staffing and BEmONC training status at HCs, KOICA/UNICEF Baseline survey, ...... 78 Oromia and SNNP, March 2017 Table 32: HC ANC room setup, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 ...... 78

Table 33: Availability of equipment, supplies and drugs at HC ANC, KOICA/UNICEF Baseline ...... 79 survey, Oromia and SNNP, March 2017 Table 34: Availability of ANC services at HC, ANC, KOICA/UNICEF Baseline survey, Oromia and ...... 80 SNNP, March 2017 Table 35: Recording and reporting at HC ANC, KOICA/UNICEF Baseline survey, Oromia and ...... 80 SNNP, March 2017 Table 36: Staffing of delivery units and BEmONC training status at HCs, KOICA/UNICEF Baseline ...... 82 survey, Oromia and SNNP, March 2017 Table 37: Observation of delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia and ...... 83 SNNP, March 2017 Table 38: Maternity beds, rooms and floor materials of delivery units at HCs, KOICA/UNICEF ...... 84 Baseline survey, Oromia and SNNP, March 2017 Table 39: Job aids and guidelines in the delivery units at HCs, KOICA/UNICEF Baseline survey, ...... 85 Oromia and SNNP, March 2017 Table 40: Equipment and supplies in the delivery units at HCs, KOICA/UNICEF Baseline survey, ...... 86 Oromia and SNNP, March 2017 Table 41: Quantity of delivery related equipment in the delivery units at HCs, KOICA/UNICEF ...... 87 Baseline survey, Oromia and SNNP, March 2017 Table 42: Readily availability of drugs related to delivery services at HCs, KOICA/UNICEF Baseline ...... 87 survey, Oromia and SNNP, March 2017 Table 43: Availability of services and fees for women in labor at HCs, KOICA/UNICEF Baseline ...... 88 survey, Oromia and SNNP, March 2017

Table 44: Availability of equipment, supplies and drugs in the delivery units at HCs, ...... 91 KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 Table 45: Types of professionals providing PNC services at HCs, KOICA/UNICEF Baseline survey, ...... 92 Oromia and SNNP, March 2017 Table 46: Assessment of service areas at PNC units at HCs, KOICA/UNICEF Baseline survey, ...... 92 Oromia and SNNP, March 2017 Table 47: Availability of equipment, supplies and drugs at PNC units at HCs, KOICA/UNICEF ...... 93 Baseline survey, Oromia and SNNP, March 2017 Table 48: Availability of guidelines, job aids and formats at PNC units at HCs, KOICA/UNICEF ...... 94 Baseline survey, Oromia and SNNP, March 2017 Table 49: Availability of guidelines, job aids and formats at under five clinics at HCs, ...... 95 KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 Table 50: Availability of equipment, supplies, guidelines, job aids and formats at under five clinics at ...... 95 HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 Table 51: Availability of IMNCI drugs on the day of assessment and stock out status at HCs, ...... 97 KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 Table 52: Distribution of surveyed hospitals by region, Zone, and type: UNICEF/KOICA Baseline ...... 98 survey, March 2017 Table 53: Equipment, drugs, supplies and job aids availability in primary hospitals; KOICA/UNICEF ...... 100 Baseline survey, Oromia and SNNP, March 2017 Table 54: Services provided at ANC in primary hospitals; KOICA/UNICEF Baseline survey, Oromia ...... 101 and SNNP, March 2017 Table 55: Distribution of delivery service providers at primary hospitals by level of health care ...... 102 professionals; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 Table 56: Trained staff on BEmONC; KOICA/UNICEF Baseline survey, Oromia and SNNP, March ...... 102 2017 Table 57: Distribution of maternity beds by hospital; KOICA/UNICEF Baseline survey, Oromia and ...... 103 SNNP, March 2017. Table 58: Availability of treatment guidelines at delivery unit; KOICA/UNICEF Baseline survey, ...... 103 Oromia and SNNP, March 2017 Table 59: Availability of equipment and supplies at delivery unit; KOICA/UNICEF Baseline survey, ...... 105 Oromia and SNNP, March 2017 Table 60: Readily availability of drugs when needed; KOICA/UNICEF Baseline survey, Oromia and ...... 106 SNNP, March 2017 Table 61: Distribution of services available in the surveyed hospitals; KOICA/UNICEF Baseline ...... 106 survey, Oromia and SNNP, March 2017 Table 62: Signal function status of the surveyed hospitals; KOICA/UNICEF Baseline survey, Oromia ...... 107 and SNNP, March 2017 ’ Table 63: Available equipment s and supplies for the newborn corner; KOICA/UNICEF Baseline ...... 108 survey, Oromia and SNNP, March 2017 Table 64: Availability of different professionals who provide PNC service; KOICA/UNICEF Baseline ...... 109 survey, Oromia and SNNP, March 2017 Table 65: Availability of equipment and supplies; KOICA/UNICEF Baseline survey, Oromia and ...... 110 SNNP, March 2017

Table 66: Readily availability of drugs when needed in primary hospitals; KOICA/UNICEF Baseline ...... 111 survey, Oromia and SNNP, March 2017 Table 67: NICU service area observation; KOICA/UNICEF Baseline survey, Oromia and SNNP, ...... 112 March 2017 Table 68: Procedures done in NICU; KOICA/UNICEF Baseline survey, Oromia and SNNP, March ...... 113 2017 Table 69: Equipment and supplies at the NICU; KOICA/UNICEF Baseline survey, Oromia and ...... 113 SNNP, March 2017 Table 70: Availability of diagnostic services in NICU; KOICA/UNICEF Baseline survey, Oromia and ...... 115 SNNP, March 2017 Table 71: Availability of guidelines, job aids, and formats at NICU; KOICA/UNICEF Baseline ...... 116 survey, Oromia and SNNP, March 2017 Table 72: Availability of drugs; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 ...... 116

Table 73: Availability of equipment in the under-five clinic; KOICA/UNICEF Baseline survey, ...... 117 Oromia and SNNP, March 2017 Table 74: Availability of UNEXPIRED drugs, stock of status and average duration; KOICA/UNICEF ...... 118 Baseline survey, Oromia and SNNP, March 2017

List of figures

Figure 1: Signal functions in the delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia ...... 89 and SNNP, March 2017 Figure 2: Status of facility practice of signal functions in the delivery units KOICA/UNICEF ...... 89 Baseline survey, Oromia and SNNP, March 2017.

Acronyms

ABH ABH Services PLC ANC Ante Natal Care ARI Acute Respiratory Infection ART Anti Retroviral Treatment BEmONC Basic Emergency Obstetric and Newborn Care CAPI Computer Assisted Personal Interviewing CBN Community Based Nutrition CBNC Community Based Newborn Care CEmONC Comprehensive Emergency Obstetric and Newborn Care CSA Central Statistical Agency CSPro Census and Survey Processing System DHS Demographic and Health Survey EDHS Ethiopia Demographic and Health Survey FGD Focus Group Discussion FMOH Federal Ministry of Health GIS Geographic Information System HC Health Center HEP Health Extension Programme HIV Human Immunodeficiency Virus HP Health Post HW Health Worker ICCM Integrated Community Case Management IFHP Integrated Family Health Programme IMNCI Integrated Management of Neonatal and Childhood Illness IMR Infant Mortality Rate MDGs Millennium Development Goals MNCH Maternal, Newborn and Child Health 10

NGO Non Governmental Organization NICU Neonatal Intensive Care Unit ODK Open Data Kit PLC Private Limited Company PMTCT Prevention of Mother-to- Child Transmission PNC Post Natal Care RFP Request for Proposal RHB Regional Health Bureau SBA Skilled Birth Attendant SNNP Southern Nations, Nationalities, and Peoples UNICEF United Nations Children's Fund WHO World Health Organization

Executive Summary

Introduction Ethiopia set a target to reduce maternal mortality to 199 per 100,000 live births, under-five mortality 30 per 1000 live births, neonatal mortality to 10 per 1000 live births by the end of 2020. To achieve the targets, different programmatic strategies are developed. The programmatic strategies targeting child survival at health facility and community level include IMNCI), ICCM, CBNC, Newborn Corner Initiative, NICU, Pediatric Referral Care, Nutrition Programme, EPI, PMTCT and Pediatric Antiretroviral Treatment (ART), Maternal Health Programmes, and Health Service Quality Improvement Programme. All of the community based Health interventions are conducted through Health Extension Program platform. After the successful implementation of ICCM through a government led coordination mechanism, FMoH endorsed the introduction of neonatal sepsis management into the Health Extension Programme (HEP). In collaboration with the FMOH, RHB, Professional associations, NGOs, donors and academic institutions, the UNICEF-KOICA MNCH project aims to scale up maternal and new-born care in 5 zones covering a total population of 4 million. This project will contribute to the national scaling up of evidence based interventions to improve maternal and new-born health at the community and health – facilities. The proposed project period is 2015 2018. UNICEF with its partners contracted ABH Services PLC to conduct baseline assessment in Segen, Bench Maji, and Keffa zones of SNNP region, and Jimma zone of Oromia region. The objectives of the baseline survey are to assess the awareness and knowledge of mothers on MNCH services, assess the utilization of MNCH services, assess the quality of MNCH services, and identify the critical challenges of using MNCH services.

Methods The assessment was conducted in Segen, Bench Maji, and Keffa zones of SNNP Region and Jimma zone of Oromia Region. Both community-based and health institution based studies were conducted. The baseline survey used mixed methods design. Quantitative study was conducted in the community and health institutions. The respondents of the quantitative community based study were mothers who have under-one year infants. The final sample size estimated for the community based study was 1,058. Multistage sampling technique was applied to select the administrative areas and study subjects. All the three intervention zones in SNNP and Jimma Zone Oromia Region (Jimma) were included in the survey. A total of 12 woredas, and 48 kebeles, and 1058 households were selected by simple random sampling technique. For health institution based study, 48 health posts, 48 health centers, seven primary hospitals and one general hospital were included. A total of 110 in-depth interviews and 24 FGDs were also conducted. Participants of the in-depth interview and FGD were selected purposively. Structured questionnaire interview was conducted with the mothers who have under-one year infant and health professionals in the health posts, health centers, and hospitals. Observation was applied to collect data on the availability of drugs, equipments, and facilities in the health institutions. Quantitative data were collected using electronic data collection device and software. Data collected by tablets using CSPro software was exported to SPSS version 20 for analysis. The objectives of the study and the indicators documented in the Monitoring and Evaluation Plan of UNICEF/KOICA guided the data analysis. The qualitative data collection team did the transcription while they were in the

field. Qualitative data was imported to Open Code software Version 4.02 after converting the word file to text file. Data were analyzed using thematic content analysis technique. Results A total of 1051 mothers were interviewed. Nine hundred fifty nine (91.2%) women reported that they have ever heard about ANC, 720 (68.5%) ever heard about PNC, 631 (60.0%) ever heard about CBNC, and 514 (48.9%) mothers ever heard about ICCM. Based on the operational definition, 233(22.2%) women have good knowledge on ANC, 315(30.0%) on the advantages of delivering in health institutions, 139 (13.2%) on PNC, 161 (15.3%) on CBNC, and 212 (20.2%) mothers have good knowledge on ICCM. Seven hundred ninety four (75.5%) mothers attended ANC during their last pregnancy, 800 (76.1%) delivered in health institutions, and 439 (41.8%) attended PNC. Three hundred and six (29.1%) started PNC within 72 hours after birth. Sixty one (85.9%) sick newborns were treated by health professionals. A total of 30(93.8%) children age 2 months to less than one year old with ARI, 65 (90.6%) with fever, and 36 (85.7%) children with diarrhoea were also treated by health professional. Wealth quartile, HEW home visit during pregnancy, and availability of family health guide in the house have significant association with ANC service utilization. Zone, religion, age of mother, wealth quartile, HEW home visit during pregnancy, ANC service utilization, and knowledge on the advantages of delivering in health institutions have significant association with skilled birth attendance (health institution delivery). Religion, marital status, HDA visit during pregnancy, HEW home visit during pregnancy, ANC service utilization, and health institution delivery have significant association with NBC utilization.

Seven hundred seventy seven (97.9%) women have favourable perception on the quality of ANC services, 785 (98.1%) women on the quality of delivery services, 250 (94.7%) women on the quality of PNC, 51(83.6%) women on the quality of NBC services, and 79 (92.9%) women have favourable perception on the quality of child care services.

Generally, there is demand for MNCH services. Eight hundred eighty two (83.9%) women expressed their feeling that more women are seeking ANC care in health institutions and 890 (84.7%) feel that more women are delivering in the health institutions. On the other hand, only 659(62.7%) women feel that more women are seeking PNC in health institutions. Similarly, 819(77.9%) of the women feel that more women are seeking NBC in health institutions and 826 (78.6%) have the impression that more women are seeking child care in health institutions. . A total of 330 women or children were referred to higher level health institutions. Most of them were referred from health post to health center (63.6%), and from health center to primary hospital (28.5%). Out of the total 330 referred mothers and children, 320 (97.0%) managed to go the referral sites. Mothers/ children used ambulance and cars/bajaj equally (122 each) to go to the referral sites. Ambulances were the major means of transport when labouring mothers were referred to the higher level health institutions. In other circumstances, private cars or bajajs were used to take the mothers and children to the referral site.

The health institution survey has covered 103 facilities, 47 HPs, 48 HCs, 7 primary hospitals, and 1 general hospital. ANC services were available in 44 (93.6%) HPs, 48 (100%) HCs, and 6 primary hospitals. PNC services were available in 40 (93.6%) HPs, and in all HCs and 13

primary hospitals which provide delivery services. At HP level, maternal services were given by the HEWs. Diploma midwives were the major workforce both at HC and primary hospital level and most are trained on BEmONC. None of the primary hospitals have OBGY specialist. BF, FP and nutrition counseling and advice on birth preparedness and complication readiness (BPCR) were given in all facilities providing ANC, delivery and PNC services. Immunization service was available in 42 (95.5%) HPs, 44 (91.7%) HCs, and in all primary hospitals. Twenty (45.5%) HPs, 38 (79.2%) HCs and two thirds of primary hospitals deworm pregnant women during ANC. Hemoglobin measurement services were available in 21 (43.8%) HCs, and all hospitals. All hospitals and 30 (62.5%) HCs were giving PMTCT Option B plus. In-patient service to pregnant women was available in 15 (31.1%) and ART in 16 (33.3%) HCs. The most practiced signal function at HC level was assisted vaginal delivery, done in 36 (76.6%) and the least were use of corticosteroids in preterm labor and magnesium sulphate for [pre-] eclampsia. All signal functions were practiced at primary hospital levels except for blood transfusion done in 5 facilities. Operative delivery service was available in all the primary hospitals assessed and performed by IESO. Blood transfusion service was available in 4 primary hospitals.

Functional BP apparatus was present in 30 (63.8%) HPs, 45 (95.7%) HCs and in all primary hospitals. Adult weighing scale was available in 40 (90.9%) HPs, 40 (83.3%) HCs, and in 4 primary hospitals. Iron/iron folate tablet was available in 31 (77.5%) HPs, 29 (60.4%) HCs and 4 primary hospitals. None of the HCs have access to ultrasound services, 9 (19.5%) possess Doppler, 6 (12.7%) had pulse oximeter. Oxygen cylinder was available in 9 (18.8%) HCs and in 3 primary hospitals. Overall emergency drugs were available in less than half of the facilities surveyed. The number of maternity beds at the primary hospitals range from 1 to 21.

Health services for under-five children were available in 44 (93.6%) HPs, 48 (100%) HCs and all primary hospitals surveyed. Functional newborn corner was available in 20 (42.6%) HCs and all primary hospitals. NICU services were established and functional in all the 7 primary hospitals and one general hospital. Child health services were predominantly provided by midwives and clinical nurses in the HCs and hospitals. None of the hospitals had paediatrician. Close to 90% of staffs at HP level have received training on ICCM and CBNC. – In the last 3 months preceding the survey 29 (69.0%) HPs have managed infants 0 2 – months, 21 (72.4%) HP have referred infants 0 2 month for very server disease, 12 (41.4%) – have treated infants 0 2months with gentamycin injection for sepsis. Main services provided at NICU were IV canalization, treatment of sepsis, oxygen administration, umbilical catheterization, management of asphyxia and hypothermia. Three primary hospitals have given blood transfusion and phototherapy. Only one facility did CPAP for hyaline membrane disease. None of the NICU have provided plasma transfusion, exchange transfusion, or surgical correction of congenital diseases. No medical bioengineer, neonatologist or pediatrician at the NICUs. KMC was available in 6 hospitals.

Amoxacillin dispersible tablet was available in 31 (66%) HPs. Amoxicillin suspension was present in 15 (31.9%) HPs, 37 (77.1%) HCs, and 6 of the 7 primary hospitals. ORS was ’ available in 31 (66%) HPs, 37 (77.1%) HCs, and all 7 primary hospitals. Plumpy nut was available in 8 (17%) HPs, 31 (64.6%) HCs, and in 6 of the 7 primary hospitals. Zinc was available in 38 (80.9%) HPs, 46 (95.8%) HCs, and in 5 of the 7 primary hospitals. RDT, Tetracycline eye ointment, cotrimoxazole, gentamycin 10mg/ml injection, folic acid were available in less than 50% of HPs.

Only 6 (12.8%) HPs have neonatal resuscitation bag and 5 (10.6%) had face mask size 0 and 1. Suction bulb was available in 3 HPs. Neonatal resuscitation bag was available in all HC, and 6 of the 7 primary hospitals. Size 0 and 1 face mask was available in 35 (74.5%) HCs and 3 primary hospitals. All NICUs have radiant warmer, 7 had oxygen cylinder in use, neonatal bed, functional oxygen concentrator and laryngoscope set. Only two NICU had functional pulse oximeter. Functional electronic, neonatal sphygmomanometer was available only in one NICU. None of the NICU had exchange transfusion set, neonatal vital sign monitoring system and functional hub cutter.

In terms of facility structure, piped water connection was available in 4 (8.5%) HPs, 25 (52.1%) HCs, and all hospitals. Most facilities were having interruption of water supply on the day of the visit. Electric grid was the power source in 5 (10.6%) HPs, 27 (56.2%) HCs and all hospitals. Ambulance service was accessible for 38 (80.9%) HPs, 46 (95.8%) HCs and all hospitals. Twenty seven (56.3%) HCs had motorized transport for referral. In all facilities referral systems were in place.

The major critical challenges for utilizing MNCH services include lack of awareness; inaccessibility of health institutions; unavailability of MNCH services, equipment, drugs, and other supplies; lack of rooms; unavailability of maternity waiting rooms and lack of food and facilities in the maternity waiting rooms; shortage of skilled man power; staff behaviour problems; culture and religion influences on utilization of MNCH services; challenges within the family; lack of water and electricity; communication challenges; and problems related to recording and reporting.

Conclusion

Mothers have high awareness on ANC services but the awareness on PNC, CBNC, and ICCM is low. Relatively higher percentages of women have good knowledge on the advantages of delivering in health institutions. The knowledge level of mothers on PNC and CBNC is especially low. Women in Jimma Zone of Oromia Region have better knowledge on MNCH services compared to the 3 zones together in SNNP Region. ANC service utilization and health institution delivery rates are higher than EDHS 2016 report and the targets set by UNICEF-KOICA MNCH project at the end of 2018 but the percentage of mothers who received PNC within 72 hours is much lower (29.1%) than the target set by UNICEF-KOICA MNCH project (75.0%). The percentage of newborns with health problems that were treated at home or health institutions is already higher than the target set by 15

UNICEF-KOICA MNCH project. Similarly, higher percentages of children with ARI, fever and diarrhoea were treated by health workers compared to the findings of EDHS 2016. Considering modifiable risk factors, home visit by HEWs during pregnancy positively influenced ANC, health institution delivery, and NBC. Availability of family health card in the house also has a positive effect on utilization of ANC services. Additionally, ANC service utilization, knowledge on the advantages of delivering in health institutions were the factors that have an effect on health institution delivery. Home visit by HDAs, ANC service utilization, and health institution delivery also positively influence the utilization of NBC services.

Generally, high percentage of mothers who visited health institutions has favourable perception on the quality of MNCH services. The main problems that affect quality include unavailability of services lack of laboratory services in health centers, drugs, supplies, equipment; shortage of skilled manpower; shortage of rooms; lack of water and electricity; shortage of ambulances when referral is needed. There is increasing demand for MNCH services in health institutions but the demand for PNC seems low. Demand for delivery service in health institutions is also low in some communities like pastoralists. Both ANC and PNC services are available in more than 90% of the facilities surveyed. ICCM and CBNC are the two services provided at HP. Not all HP are fully staffed as per the national recommendation. Equipment, drugs and supplies for maternal and child health services are not fully available in most HPs. Overall one can say the service readiness of the HP to provide quality MNCH service requires attention and support. The majority of HPs have access to referral services which is very encouraging. Most HPs Lack electric power supply which definitely hampers the level of service provision.

The major work forces at HC level are diploma midwives and diploma clinical nurses. Most health workers have received training in the respective service area. Four fifth of the surveyed HCs have staff trained on BEmONC. The BEmONC training focused predominantly on midwives while diploma clinical nurses are still responsible for provision of good proportion of maternal services. Most of them are practicing the signal functions. Only 20 (42.6%) delivery units fulfil the three parameters for a functional newborn corner. IMNCI service is provided in all surveyed health centers. Except for examination couches, stethoscopes and sterile gloves there are shortages of equipment, supplies and drugs needed for maternal and child health services in the health centers. Basic laboratory and inpatient services are not strong adequate. Only close to half of the facilities have functional newborn corner though still lacking some of the components like oxygen, radiant heater etc., which could show that readiness to provide quality essential newborn care is a work on progress.

In most hospitals, maternal health services are provided predominantly by midwives. None of the hospitals are staffed by OBGY specialist or EOS trained GPs that could affect the quality of services provided. Most staffs are trained on BEmONC. The primary hospitals have most of the services required for maternal health services including cesarean section, though one third of them lack blood transfusion services. Most primary hospitals lack the complete equipment to provide essential care such as neonatal size face mask and oxygen bottle. All NICU have radiant warmer and incubator set. Only one hospital NICU has CPAP. Operative 16

delivery services is provided in all hospitals and two third have blood transfusion services. Shortages of drugs and supplies are observed in several hospitals. There are referral systems established at all levels which is very encouraging. Child health services are available in all hospitals. Like the maternal services, child health services are mainly provided by midwives and clinical nurses. All the NICU are level I units. At least the units should be staffed by a pediatrician to be level II NICU not taking account the lack of certain equipment like vital sign monitors, transfusion sets and related services. The major challenges identified by the qualitative research regarding the critical challenges of utilizing MNCH services were lack of awareness; inaccessibility of health institutions; unavailability of MNCH services, equipment, drugs, and other supplies; lack of rooms; unavailability of maternity waiting rooms and lack of food and facilities in the maternity waiting rooms; shortage of skilled man power; staff behaviour problems; culture and religion influences on utilization of MNCH services; challenges within the family; lack of water and electricity; communication challenges; and problems related to recording and reporting. Recommendation  Awareness creation on different MNCH services by different strategies like availing family health cards, enhancing health education program at community and health institution level are essential.  Religious leaders and other influential people in the community need to be involved in the advocacy, communication, and social mobilization  Construction of health institutions close to the community to make services accessible. Related to this, re-mandating the health posts to provide delivery services after appropriate training and availing of the necessary facilities and equipments may be considered.  Employing sufficient number of qualified health professionals and providing ongoing training to the staff on different MNCH components  Frequent supportive supervision and mentoring as well as periodic experience sharing is necessary.  There shall be a strong, consistent and accountable system of distribution of supplies and drugs to address shortages on ongoing basis. Focus also should be given to non- traditional supplies, drugs and equipment that are very critical to save the lives of patients.  Guidelines and job aids shall be provided and personnel doing supportive supervision shall ensure its placement at service delivery points.  Availing sufficient number of ambulances  Construction of roads and availing other infrastructure like water and electricity  Construction of sufficient number of rooms in the health institutions  Construction of maternity waiting areas in health centers and providing sufficient food and facilities to the mothers

1. Introduction

The Ethiopia Demographic and Health Survey (EDHS) 2016 reported MMR of 412 per 100,000 live births in Ethiopia[1]. According to the UNICEF report in 2015, Under-five mortality rate decreased in Ethiopia from 205 per 1,000 live births in 1990 to 59 per 1,000 live births in 2015. That means Ethiopia has achieved the under-five mortality MDG target of 68 per 1,000 live births. Similarly, the Infant Mortality Rate (IMR) decreased from 122 per 1,000 live births in 1990 to 41 per 1,000 live births in 2015. Though the reduction rate was lower compared to under-five and infant mortality rates, neonatal mortality rate (NMR) also decreased from 61 per 1,000 live births in 1990 to 28 per 1,000 live births in 2015[2]. The EDHS 2016 also reported NMR of 29 per 1,000 live births, IMR of 48 per 1,000 live births, and U5MR of 67 per 1,000 live births[1].

Different high impact interventions are designed to reduce maternal, newborn and child mortality. Among other interventions, the services targeted to mothers include antenatal care (ANC), delivery care, and post natal care (PNC)[3]. According to the EDHS 2016 report, 62 % of women received ANC from skilled provider and 26% of the women delivered in a health facility. Few percentages of women (17%) had postnatal check up in the recommended first 2 days after birth. Thirty percent of children under-five years with symptoms of ARI in the last two weeks sought advice/treatment from health care facility and 35% sought advice/treatment when they had fever. Forty three percent of under-five children sought treatment when they had diarrhoea[4]. A survey conducted on community based newborn care in Amhara, Oromia, SNNP, and Tigray regions reported that 41 % of mothers sought formal medical care when their newborns had symptoms of an illness[5].

Ethiopia set a target to reduce maternal mortality to 199 per 100,000 live births, under-five mortality 30 per 1000 live births, neonatal mortality to 10 per 1000 live births by the end of 2020. To achieve the targets, different programmatic strategies are developed. The programmatic strategies targeting child survival at health facility and community level include Integrated Management of Neonatal and Childhood Illness (IMNCI); Integrated Community Case Management (ICCM); Community Based Newborn Care (CBNC); Newborn Corner Initiative; Neonatal Intensive Care Unit (NICU); Pediatric Referral Care; Nutrition Programme; Expanded Programme of Immunization; Prevention of Mother-to- Child Transmission of HIV (PMTCT) and Pediatric antiretroviral treatment (ART); Maternal Health Programmes; and Health Service Quality Improvement Programme. All of the community based Health interventions are conducted through Health Extension Program platform. After the successful implementation of ICCM through a government led coordination mechanism, FMoH endorsed the introduction of neonatal sepsis management into the Health Extension Programme (HEP)[6].

The national CBNC guideline lists out seven key components of the program which are in line with other initiatives to improve maternal and newborn health outcomes. These components are early identification of pregnancy; provision of focused antenatal care (ANC); promotion of institutional delivery and Safe and clean delivery including provision of 18

misoprostol in case of home deliveries or deliveries at health post level; provision of immediate newborn care including application of chlorohexidine on cord; recognition of asphyxia, initial stimulation and resuscitation of newborn baby; prevention and management of hypothermia; management of pre-term and/or low birth weight neonates; and management of neonatal sepsis/very severe disease at community level [3].

In collaboration with the FMOH, RHB, Professional associations, NGOs, donors and academic institutions, the UNICEF-KOICA MNCH project aims to scale up maternal and new-born care in 5 zones covering a total population of 4 million. This project will contribute to the national scaling up of evidence based interventions to improve maternal and new-born – health at the community and health facilities. The proposed project period is 2015 2018 and the expected results are: 80% of pregnant women receive at least one antenatal care; 25% of all births take place in health facilities; 80% of new-borns initiate breastfeeding within one hour after birth; 75% of new-borns and mothers received PNC visits by HEWs within 72 hours; 50% of new-borns with infections receive effective treatment at health posts or/and health centres; 80% of health centres will have at least two trained staff in Basic Emergency Obstetric and New-born Care and Integrated Management of New-born and Childhood Illnesses respectively and 80% of health centres with a maternity ward/delivery service have a functional new-born corner.

Even though this survey is considered as a baseline survey, in real sense the survey is done in the middle of the project implementation time that most of the results of this survey are expected to be higher than what would have been found had the survey was done before implementing the interventions. This can be considered as limitation of this baseline survey.

UNICEF with its partners contracted ABH Services PLC, an affiliate of Jimma University, to conduct baseline assessment in Segen, Bench Maji, and Keffa zones of SNNP region; and Jimma zone of Oromia region.

2. Objectives

The objectives of the base line survey were: 1) Assess awareness and knowledge of mothers on high impact MNCH services in the project intervention areas. 2) Determine the level of utilization and associated factors of high impact maternal health services, newborn health services (including utilization of treatment for newborns with sepsis at community level), and child health services during the first year of life. ’ 3) Assess mothers perceived quality of high impact MNCH services in the project intervention areas. 4) Explore the demand for high impact MNCH services - ANC, SBA, ICCM, CBNC, Newborn Corner, NICU, and BEmONC.

5) Examine the actual referral linkage process and mechanisms in place for Maternal and newborn cases within the primary care units/delivery platform 6) Assess the availability of key selected high impact MNCH services - ANC, SBA , ICCM, CBNC , Newborn corner , NICU , and BEmONC 7) Determine the availability of current key essential MNCH drugs and supplies, and the availability and functionality of equipment for ICCM, CBNC , Newborn corner , NICU, and BEmONC 8) Assess the quality of key selected high impact MNCH services - ANC , SBA , ICCM, CBNC , Newborn corner , NICU , and BEmONC 9) Identify critical challenges with regard to MNCH services utilization both from demand and supply side.

3 Methods

3.1 Study area and population

The assessment was conducted in Segen, Bench Maji, and Keffa zones of SNNP Region and Jimma zone of Oromia Region. There are 5 woredas in Segen Zone, 11 woredas in Bench Maji Zone, 11 woredas in Keffa Zone, and 18 woredas in Jimma zone. Based on the CSA projection for 2016, the 4 zones have a total population of about 5,776,031[7]. In 2016, the estimated number of under-two month old infants in the 4 intervention zones was 22,680. The numbers of under-one year infants and women 15-49 years old were estimated to be about 136,078 and 1,349,657, respectively. There were a total of 7 primary hospitals, 199 health centers, and 966 health posts in the four intervention zones.

3.2 Study design and study subjects/units

Both community-based and health institution based studies were conducted. The baseline survey used mixed methods design. The purpose of applying mixed methods was mainly to triangulate findings of the quantitative and qualitative study. While cross sectional design was applied for the quantitative study, phenomenological research design was used for the qualitative study where the experience of the mothers and other stakeholders was gathered in detail by conducting in-depth interview and FGDs. Quantitative study was conducted in the community and health institutions. The respondents of the quantitative community based study were mothers who have under-one year infants. They gave information on maternal, newborn, and child health related issues. The child health related questions targeted infants under-one year. On the other hand, for health institution based quantitative study, health professionals in charge of MNCH services in the health posts, health centers, and primary hospitals responded to different questions related to availability and quality of MNCH services. In addition, general hospitals in the 4 zones were considered for assessment of NICU. Respondents of the qualitative study were identified from the community, health institutions, woreda health office, and zonal health department.

3.3 Sample size and sampling techniques Quantitative study Sample size and sampling technique

Sample size was estimated both for cross sectional design and pretest-post test evaluation design without control group. The sample size estimated for the cross sectional study using single population proportion formula was larger than the sample size for the pretest-posttest evaluation design. Hence, to be safe with regard to the number of mothers and children to be included in the study, the sample size calculated using the formula for single population proportion was taken as the final sample size for the baseline survey. The maximum sample ‘ size calculated was 962 which was the sample size calculated using Percentage of births ’ attended by skilled health personnel as indicator. Adding 10% for possible non-response, the final sample size was 1,058 households.

The overall sampling technique was multistage. All the three intervention zones in SNNP (Segen, Keffa, and Bench Maji) and one zone in Oromia (Jimma) were included in the survey. From the total 45 woredas in the 4 zones, 12 were selected using lottery method. Since 60% of the woredas were from SNNP, and considering the heterogeneity nature of SNNP, 8 woredas were selected from SNNP and the remaining 4 were from Oromia region (Jimma Zone). Based on the total number of woredas in each zone, 2 woredas from Segen zone, 3 woredas from keffa zone, 3 woredas from Bench maji zone, and 4 woredas from Jimma zone were selected. From the selected 12 woredas, 48 kebeles (4 kebeles per selected woreda) were randomly selected. The selected kebeles from each woreda were from different PHCU. Then, 1058 households from the 48 selected kebeles (nearly 22 households per kebele) were selected by simple random sampling technique using random number generator based on the lists of households where there are mothers who have under-one year infant. The list of household with women who have under-one year infant in the selected kebeles was initially obtained. In kebeles where such list is not available, listing of households was done by the research team.

For health institution based study, the sample size calculated using the pretest-posttest design is used regarding the minimum number of health centers to be included in the study. A minimum of 11 health centers are required based on the sample size calculated. But, since the total number of kebeles to be included in the household survey was 4 in each selected woreda, similar number of PHCUs was considered for inclusion in the study. Accordingly, in each selected PHCU, one health center and one health post were included in the study. The health post within the selected PHCU was selected by lottery method. A total of 48 health posts, 48 health centers, seven primary hospitals, and one general hospital were included in the baseline survey.

Qualitative study Sample size and sampling technique

In-depth interview was conducted to collect information from experts in charge of MNCH services at zonal health departments and woreda health offices, kebele administrators, HEWs, health professionals in charge of MNCH services in the health centers, health professionals in charge of MNCH services in primary hospitals, liaison officers in the primary hospitals, and ambulance drivers. Additionally, FGD was conducted with members of HDA and mothers who have <1 year infant. Data collection continued until saturation is reached. A total of 110 in-depth interviews and 24 FGDs were conducted. Participants of the in-depth interview and FGD were selected purposively.

3.4 Data collection Techniques and tools

Different data collection techniques (methods) were applied for the baseline survey which includes structured questionnaire interview, observation, FGD, and in-depth interview.

A) Structured questionnaire interview

Structured questionnaire interview was conducted with the mothers who have under-one year infant. These women who had given birth in the past one year were asked a number of questions about maternal, newborn, and child health care services utilization. Mothers were asked whether they had obtained antenatal care during the pregnancy for their most recent live birth in the past one year. Questions related to delivery care, postnatal care, newborn care, and child care were also regarding the most recent delivery in the past one year. Newborn care in the context of this research covers the time from birth to less than 2 months after delivery. Child health services utilization questions addressed infants from 2 months to less than one year. The questionnaire were initially prepared in English and translated to Amharic and Afan Oromo. People who speak the local language recruited to collect data. Responsible health professionals in the health posts, health centers, and hospitals were also interviewed using check list to assess the availability of key MNCH services, essential MNCH drugs, supplies, equipment and facilities.

Operational definition

In addition to analyzing each question separately, operational definitions were developed to combine the responses of different questions related to the variable of interest. In this regard,

two of the variables which required operational definition are knowledge on high impact MNCH services, and perceived quality of high impact MNCH services.

Different selected questions related to knowledge on MNCH services were prepared. A total of 23 questions related to ANC knowledge, eight questions related to knowledge on the advantages of delivering in health institutions, 18 questions related to knowledge on PNC, 17 questions related to knowledge on CBNC, and five questions related to knowledge on ICCM were asked. Those respondents who correctly answered 50% or more of the knowledge questions related to the different components of MNCH were considered as having good knowledge and those who correctly answer less than 50% of the questions were considered as having poor knowledge.

Perceived quality of high impact MNCH services were assessed by using a five point likert scale. The scale values were 5=Very satisfied, 4=Satisfied, 3=indifferent, 2=Dissatisfied, 1=Very dissatisfied. Nine statements related to perceived quality of the different MNCH services were identified. Those mothers who visited health institutions including health posts were asked their perception on the quality of MNCH services. The scores were added to form a total score. Those who score above the sum of the middle value (27) of the likert scale were considered as having favourable perception/attitude and those who score at or below the middle value (27) were considered as having unfavourable perception on the quality of MNCH services.

B) Observation

Observation was applied to collect data on the availability of drugs, equipment, and facilities in the health institutions. Check list consisting of the necessary drugs, equipments, facilities, records etc were prepared and used.

Regarding data collection for the quantitative survey using questionnaire interview and observation, data were collected using electronic data collection device and software. CSPro software using tablet computers with windows or android operating system was used. An experienced CAPI/CSPro specialist was employed to manage all issues related to electronic data collection together with other members of the research team. By using CSPro software, data collection templates were developed and data was collected using the template and sent to the server which was web based. Data collectors were given tablet computers for this purpose. They were trained on how to use the tablet computers for data collection.

C) In-depth interview

Semi-structured questions were used to collect data during in-depth interview. Saturation was reached after conducting 110 in-depth interviews. Each in-depth interview took 45 to 60 minutes and was conducted by experienced and trained interviewers. In addition to taking notes, the interviews were tape recorded. The interviewers themselves did the transcription in the field.

D) Focus Group Discussion (FGD)

FGDs were conducted with members of HDA and women who have under-one year infant. Emerging themes were entertained and carried to all the following FGDs. Professionals with proven experience in qualitative data collection were deployed to facilitate FGDs. All FGDs were conducted in local languages and translated into English. FGD sessions were carried out in natural settings that enabled discussants to express their thoughts and opinions – comfortably. Each FGD session constituted 8 12 participants. Each FGD lasted between 60 and 75 minutes. Additional to notes taken during the discussion, all interviews were audio taped. The facilitators of the discussion themselves did the transcription in the field. To cope- up with the limited time, transcribed data and field notes were send from field to the key personnel who made the ultimate decision on when and if saturation is reached.

3.5 Data quality control

Pre-test was done in Mojo. Data collectors for both the quantitative and qualitative study were those who have previous experience of collecting quantitative and qualitative data. The data collectors speak the local language in the respective zones. Interpreters were also used when ever there was a need. This especially happened in SNNP Region. Appropriate training was given to the field staff. The research team also supervised the data collection in the field. The fact that electronic data collection was done reduces errors. Description of the GIS ’ coordinates of respondents location at the time of interview also helped to check whether the data collector has really visited that specific house. Data was checked at the field for any error by the supervisors and corrections were done on site. The CAPI/CSPro (data manager) at the center checked for completeness and errors.

3.6 Data management and analysis Quantitative data management and analysis

Data collected by tablets using CSPro software was exported to SPSS version 20 for analysis. The objectives of the study and the indicators documented in the Monitoring and Evaluation 24

Plan of UNICEF/KOICA guided the data analysis. Proportion of women, neonates and children who used the different MNCH services was calculated. Additionally, the knowledge of women on different MHCH services and perceived quality of the services was computed for each question and dichotomized using operational definitions. Utilization of MNCH services was also computed by different socio economic status and geographic locations. Statistical tests for the presence of associations were done for ANC service utilization, skilled birth attendance (delivery in health institutions except health posts), and newborn care service utilization. Since the outcome variables were dichotomized, bi-variate and multivariate logistic regression were applied to assess associations. Backward stepwise method was used during multivariate logistic regression. The common independent variables fitted into the multivariate logistic regression model were zone, residence (urban Vs rural), age of the mother, marital status, religion, education status, occupation, wealth index, home visit by HDAs during pregnancy, home visit by HEWs during pregnancy, and availability of family health guide in the house. Additionally, knowledge on ANC services was added in the list of independent variables when assessing association with ANC service utilization. ANC service utilization and knowledge on the advantages of delivering in health institutions were also considered as independent variables for health institution delivery. Additional variables considered when assessing the factors for NBC service utilization were health institution delivery and knowledge on CBNC. These variables were fitted into the multivariate logistic regression model whether they showed significant association or not during the bi-variate analysis. Adjusted odds ratios (AORs) with their confidence intervals are reported. For the quantitative assessment of the different services, drugs, supplies and equipment etc, indicators like percentages of health institutions who provide the services; have the key MHCH drugs; have the supplies; have functional equipments etc are calculated.

Qualitative Data Management and Analysis

The qualitative data collection team did the transcription while they were in the field. Qualitative data was imported to Open Code software Version 4.02 after converting the word file to text file. Data were analyzed using thematic content analysis technique by the key research team after coding and synthesizing the data. Direct verbatim and results from the coding and categorization were used to develop a report.

4 Ethical considerations

Issues related to ethical clearance and permission from responsible government offices was obtained by ABH Services PLC. UNICEF Ethiopia provided the necessary support letters to get the ethical clearance and other supports as needed. ABH Services PLC obtained informed verbal consent from the study participants. Information provided by participants were kept confidential by employing different strategies like not writing personal identifiers on the questionnaire and limiting access to data only to those people who are responsible for data management and analysis. When sick women and children are found during data collection, they were linked to the nearby health institutions for managing their health problems. 25

5. Results

5.1 Back ground characteristics of the participants of household survey

Out of the initially planned 1058, a total of 1051 mothers were interviewed making the response rate 99.3 %. Five hundred twenty two (49.7%) births were registered by Vital Events Registration Agency. Seven hundred (66.6%) respondents were from SNNP Region and 351(33.4%) were from Oromia Region. Most of the mothers (33.4%) were from Jimma Zone while the lowest numbers (16.7%) were from Segen Zone. Eight hundred nine (77.0%) were from rural area. Majority of the mothers were in the age group 25-29 years (33.6%), married (96.0%), protestant (36.9%), and Oromos (32.9%). Six hundred sixteen (58.6%) mothers had no formal education and about 72% of the mothers were house wives (Table 1).

Table 1: Background characteristics of mothers who have under-one year infant in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 ______Background characteristics N(%) Total N=1051 ______Region SNNP 700(66.6) Oromia 351(33.4) Zone Segen 176(16.7) Bench Maji 262(24.9) Keffa 262(24.9) Jimma 351(33.4) Residence Rural 809(77.0) Urban 242(23.0) Age of the mother 15-19 89(8.5) 20-24 304(28.9) 25-29 353(33.6) 30-34 197(18.7) 35-46 108(10.3) Marital status Single 29(2.8) Married 1009(96.0) Divorced/Widowed 13(1.2) Religion Protestant 388(36.9) Muslim 352(33.5) Orthodox Christian 277(26.4) Other 34(3.2) 26

Ethnic group Oromo 346(32.9) Kefficho 217(20.6) Bench 170(16.2) Konso 89(8.5) Kore 87(8.3) ’ Me ente 71(6.8) Amhara 57(5.4) Other 14(1.3) Education status of the mother No formal education 616(58.6) Primary first cycle (Grade 1-4) 184(17.5) Primary second cycle (Grade 5-8) 164(15.6) Grade and above 87(8.3) Education status of the husband No formal education 474(47.0) Primary first cycle (Grade 1-4) 156(15.5) Primary second cycle (Grade 5-8) 225(22.3) Grade 9 and above 154(15.3) Total 1009(100.0) Occupation of the mother House wife 747(71.1) Farmer 224(21.3) Merchant 38(3.6) Government employee 21(2.0) Other 21(2.0) Occupation of the husband Farmer 699(69.3) Merchant/business owner 170(16.8) Government employee 65(6.4) Daily labourer 36(3.6) Other 39(3.9) Total 1009(100.0) Wealth index First quartile 262(24.9) Second quartile 263(25.0) Third quartile 263(25.0) Fourth quartile 263(25.0) ______

5.2 Findings related to Objective 1: Assess awareness and knowledge of mothers on high impact MNCH services in the project intervention areas.

A total of 959 (91.2%) women reported that they have ever heard about ANC. Out of the 959 women who ever heard about ANC, 440(45.9%) reported the availability of family health card (folder) in their house. The major sources of information about ANC were health posts/HEWs (78.8%), health centers (33.3%), HDAs (26.5%), and friends/neighbours (23.0%). Based on the operational definition, only 233(22.2%) have good knowledge on ANC. One hundred fifty five (44.2%) women in Jimma Zone of Oromia Region had good knowledge while only 78(11.1%) in SNNP region had good knowledge on ANC. Three hundred fifteen (30.0%) have good knowledge on the advantages of delivering in health institutions. Two hundred twenty (62.7%) women in Jimma Zone of Oromia Region have good knowledge. On the other hand, only 95(13.6%) women in SNNP Region have good knowledge on the advantages of delivering in health institutions. Seven hundred twenty (68.5%) women had ever heard about PNC. Even though multiple sources of information were mentioned as source of information about PNC, 592(82.2%) heard from health posts, 404 (56.1%) heard from health centers, and 229(31.8%) heard from HDAs. One hundred thirty nine (13.2%) women have good knowledge on PNC. In Jimma Zone of Oromia Region 84(23.9%) women have good knowledge but in SNNP only 55(7.9%) have good knowledge on PNC (Table 2).

A total of 631 (60.0%) mothers reported that they have ever heard about community based newborn care (CBNC). Of those who have ever heard about CBNC, 454 (71.9%) responded that HEWs provide CBNC. One hundred sixty one (15.3%) women have good knowledge on CBNC. While 123(35.0%) women in Jimma Zone of Oromia Region have good knowledge only 38(5.4%) women in SNNP Region have good knowledge on CBNC. A total of 514 (48.9%) mothers reported that they have ever heard about integrated community case management of childhood illness (ICCM). While mothers have got information regarding ICCM from multiple sources, the major sources of information were health posts (88.3%), health centers (51.9%), and HDAs (32.7%). Two hundred twelve (20.2%) mothers have good knowledge on ICCM. In Jimma Zone of Oromia Region, 135(38.5) have good knowledge but in SNNP Region only 77(11.0%) have good knowledge on ICCM (Table 2).

Table 2: Awareness and knowledge of mothers on MNCH services in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Type of Ever heard about the service Have good knowledge about the service MNCH Bench Keffa Segen SNNP Jimma All 4 Bench Keffa Segen SNNP Jimma All 4 Service Maji Zone Zone total Zone zones Maji Zone Zone total Zone zones Zone Zone N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) Total Total Total Total Total Total Total Total Total Total Total Total N=262 N=262 N=176 N=700 N=351 N=1051 N=262 N=262 N=176 N=700 N=351 N=1051 ANC 204(77.9) 245(93.5) 168(95.5) 617(88.1) 342(97.4) 959(91.2) 4(1.5) 17(6.5) 57(32.4) 78(11.1) 155(44.2) 233(22.2) Delivery ------32(12.2) 40(15.3) 23(13.1) 95(13.6) 220(62.7) 315(30.0) care PNC 138(52.7) 232(88.5) 109(61.9) 479(68.4) 241(68.7) 720(68.5) 24(9.2) 19(7.3) 12(6.8) 55(7.9) 84(23.9) 139(13.2) NBC 113(43.1) 79(30.2) 95(54.0) 287(41.0) 344(98.0) 631(60.0) 9(3.4) 11(4.2) 18(10.2) 38(5.4) 123(35.0) 161(15.3) Child care 43(16.4) 59(22.5) 82(46.6) 184(26.3) 330(94.0) 514(48.9) 28(10.7) 20(7.6) 29(16.5) 77(11.0) 135(38.5) 212(20.2)

Conclusion

Mothers have high awareness on ANC services but the awareness on PNC, CBNC, and ICCM is low. Less than 50% of the houses have family health card (folder). Relatively higher percentages of women have good knowledge on the advantages of delivering in health institutions. The knowledge level of mothers on PNC and CBNC is especially low. Women in Jimma Zone of Oromia Region have better knowledge on MNCH services compared to the 3 zones together in SNNP Region.

Recommendation

Different strategies like availing family health cards, enhancing health education program at community and health institution level is essential. More emphasis needs to be given to PNC, CBNC, and ICCM.

5.3.1 Utilization of ANC services

HDAs visited 347(33.0%) and HEWs visited 547(52.0%) mother at home during their last pregnancy. Seven hundred ninety four (75.5%) mothers attended ANC during their last pregnancy. ANC coverage was higher in Jimma Zone of Oromia Region (82.6%) compared to the three zones together in SNNP Region (72.0%). In SNNP region, ANC coverage is highest in Keffa Zone (92.4%) and is lowest in Segen Zone (39.8%). The reason for higher ANC coverage in Keffa Zone can be that relatively more urban kebeles were included in the study. Urban women attended ANC (81.8%) more than women in rural areas (73.3%). ANC attendance ranged from 73.0% among 20-24 year old women to 79.8% among 15-19 year old women (Table 3).

Table 3: Utilization of ANC services by background characteristics in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region ______Background characteristic Attended ANC______Yes No Total N(%) N (%) N(%) ______Zone Bench Maji 192(73.3) 70(26.7) 262(100.0) Keffa 242(92.4) 20(7.6) 262(100.0) Segen 70(39.8) 106(60.2) 176(100.0) SNNP total 504(72.0) 196(28.0) 700(100.0) Jimma 290(82.6) 61(17.4) 351(100.0) Total 794(75.5) 257(24.5) 1051(100.0) Residence Rural 596(73.7) 213(26.3) 809(100.0) Urban 198(81.8) 44(18.2) 242(100.0) Age of the mother 15-19 71(79.8) 18(20.2) 89(100.0) 20-24 222(73.0) 82(27.0) 304(100.0) 25-29 266(75.4) 87(24.6) 353(100.0) 30-34 156(79.2) 41(20.8) 197(100.0) 35-46 79(73.1) 29(26.9) 108(100.0) ______

Factors associated with ANC service utilization

Zone, residence (rural Vs urban), religion, age of mother, marital status, education status, occupation, wealth quartile, HDA visit during pregnancy, HEW home visit during pregnancy, availability of family health guide in the house, and ANC knowledge were fitted into the multivariate logistic regression model. Multivariate logistic regression revealed that zone, wealth quartile, HEW home visit during pregnancy, and availability of family health guide in the house have significant association with ANC service utilization. Residents of Keffa Zone have significantly higher (AOR=4.16) ANC service utilization compared to residents of Bench Maji Zone. On the other hand residents of Segen Zone are 73% less likely (AOR=0.27) to use ANC services compared to residents of Bench Maji Zone. Those women who were visited by HEWs at home during pregnancy are 2.57 times more likely to use ANC services compared to those who were not visited by HEWs. Those mothers who reported the availability of family health guide in their house are 1.85 more likely to use ANC services compared to those who reported unavailability of family health guide in their house. Mothers whose wealth index lies in the forth quartile are about four times to use ANC services compared to those in the first quartile (Table 4).

Table 4: Factors associated with ANC service utilization in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 ______Socio-economic characteristics Utilized Antenatal care service AOR 95% Confidence interval Yes No Lower Upper N(%) N(%) ______Zone Bench Maji 192(73.3) 70(26.7) Keffa 242(92.4) 20(7.6) 4.16 2.33 7.45 Segen 70(39.8) 106(60.2) 0.27 0.17 0.43 Jimma 290(82.6) 61(17.4) 2.36 1.39 4.01

Wealth quartile First quartile 147(56.1) 115(43.9) Second quartile 200(76.0) 63(24.0) 1.43 0.92 2.21 Third quartile 213(81.0) 50(19.0) 2.11 1.32 3.36 Fourth quartile 234(89.0) 29(11.0) 4.02 2.31 7.0 HEW visit during pregnancy No 338(67.1) 166(32.9) Yes 456(83.4) 91(16.6) 2.57 1.69 3.90 Family health guide availability No 451(73.8) 160(26.2) Yes 343(78.0) 97(22.0) 1.85 1.26 2.72

______

Majority of the mothers sought ANC from health centers (58.6%) and health posts (38.4%). Three hundred forty four (43.3%) women received first ANC during the 9th to 16th week of pregnancy. Five hundred seventeen (65.1%) women received ANC four and more times during their last pregnancy (Table 5).

Table 5: Sites where ANC service was provided and frequency of ANC visit in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 ______Site/frequency of visit N(%) Total N=794 ______Place where the woman initially go for ANC Health post 305(38.4) Health center 465(58.6) Government hospital 22(2.8) Other 2(0.3) Week of pregnancy when the woman first received ANC 1-8 weeks 103(13.0) 9-16 weeks 344(43.3) 17-24 weeks 278(35.0) 25-32 weeks 66(8.3) After 32 weeks 3(0.4) Number of times the woman received ANC Once 15(1.9) Twice 55(6.9) Three times 207(26.1) Four and more times 517(65.1) ______

Out of 794 women who had ANC visit, 688 (86.6%) reported that their weight was measured and for 685 (86.3%) women their blood pressure was checked. Five hundred forty two (68.3%) women reported that laboratory investigations were done during their last pregnancy ’ while 48(6.0%) didn t know or not sure whether laboratory investigations were done. The urine of 505 (93.2%) women was investigated. Four hundred fifty four (83.8%) and 406(74.9%) women reported that their blood was checked for HIV and anaemia, respectively. ’ While 288(53.1%) women reported their blood was checked for syphilis, 192(35.4%) didn t know whether their blood was checked for syphilis. Seven hundred sixty nine (96.9%) women were supplemented with iron and folic acid, and 739(93.1%) were vaccinated for tetanus. Regarding counselling services, 726 (91.4%) were advised on nutrition, 723(91.1%) on personal hygiene, 699(88.0%) on birth and emergency preparedness, and 605(76.2%) on malaria prevention such as using ITN (Table 6).

Table 6: Services provided during ANC visit in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 ______’ Type of service Yes No Don t know Total N(%) N(%) N(%) N(%) ______Weight measured during each ANC visit 688(86.6) 91(11.5) 15(1.9) 794(100.0) Blood pressure checked during each ANC visit 685(86.3) 89(11.2) 20(2.5) 794(100.0) Lab investigations done 542(68.3) 204(25.7) 48(6.0) 794(100.0) Urine investigated in the laboratory 505(93.2) 27(5.0) 10(1.8) 542(100.0) Blood checked for HIV 454(83.8) 17(3.1) 71(13.1) 542(100.0) Blood checked for anaemia 406(74.9) 12(2.2) 124(22.9) 542(100.0) Blood checked for syphilis 288(53.1) 62(11.4) 192(35.4) 542(100.0) Blood group determined 200(36.9) 64(11.8) 278(51.3) 542(100.0) Supplemented with iron and folic acid 769(96.9) 24(3.0) 1(0.1) 794(100.0) Vaccinated for tetanus 739(93.1) 54(6.8) 1(0.1) 794(100.0) Advised on nutrition 726(91.4) 51(6.4) 17(2.1) 794(100.0) Advised on personal hygiene 723(91.1) 55(6.9) 16(2.0) 794(100.0) Advised on birth and emergency preparedness 699(88.0) 70(8.8) 25(3.1) 794(100.0) Advised on malaria prevention such as use of ITN 605(76.2) 138(17.4) 51(6.4) 794(100.0) ______

5.3.2 Utilization of delivery care services

The mode of delivery for 1016 (96.7%) women was spontaneous vaginal delivery and 32(3.0%) women delivery by caesarean section (C/S). While 29(90.6%) C/Ss were done in the government hospitals, 3(9.4%) were done in the health centers. All the three C/Ss in the health centers were done in keffa Zone. Two hundred twenty five (21.4%) deliveries took place at home and 23(2.3%) took place in the health posts. Six hundred eighty eight (65.5%) deliveries occurred in health centers while 108 (10.3%) occurred in government hospitals, and 4(0.4%) occurred in hospital/clinics owned privately and by NGOs.

Overall, the deliveries of 800 (76.1%) women were attended by skilled attendants considering births in health centers, government hospitals, private hospitals/clinics, and health institutions owned by NGOs as skilled delivery. Skilled delivery rate was highest in keffa Zone (95.0%) followed by Jimma Zone (73.2%), and Bench Maji Zone (72.1%). Like that of the ANC service utilization, the high skilled birth attendance rate in Keffa Zone may to attributed to the inclusion of relatively more urban kebeles in the study. Skilled birth attendance was slightly higher in urban (77.3%) than rural areas (75.8%). The deliveries of young women were more likely to be attended by skilled attendants. Deliveries of 80 (89.9%) women age 15-19 years old , and 248(81.6%)women age 20-24 years old were attended by skilled attendants while 67(62.0%) of the deliveries of women age 35-46 years old was attended by skilled attendants (Table 7).

Table 7: Utilization of health facilities during delivery by background characteristics in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 ______Background characteristic Skilled birth attendance)*______Yes No Total N(%) N (%) N(%) ______Zone Bench Maji 189(72.1) 73(27.9) 262(100.0) Keffa 249(95.0) 13(5.0) 262(100.0) Segen 105(59.7) 71(40.3) 176(100.0) SNNP total 543(77.6) 157(22.4) 700(100.0) Jimma 257(73.2) 94(26.8) 351(100.0) Total 800(76.1) 251(23.9) 1051(100.0) Residence Rural 613(75.8) 196(24.2) 809(100.0) Urban 187(77.3) 55(22.7) 242(100.0) Age of the mother 15-19 80(89.9) 9(10.1) 89(100.0) 20-24 248(81.6) 56(18.4) 304(100.0) 25-29 258(73.1) 95(26.9) 353(100.0) 30-34 147(74.6) 50(25.4) 197(100.0) 35-46 67(62.0) 41(38.0) 108(100.0) ______

* Births that took place in health posts are not considered as skilled birth attendance

Factors associated with skilled birth attendance

Zone, residence (rural Vs urban), religion, age of mother, marital status, education status, occupation, wealth quartile, HDA visit during pregnancy, HEW home visit during pregnancy, availability of family health guide in the house, knowledge on the advantages of delivering in health institutions, and ANC service utilization were fitted into the multivariate logistic regression model. Multivariate logistic regression revealed that zone, religion, age of mother, wealth quartile, HEW home visit during pregnancy, ANC service utilization, and knowledge on the advantages of delivering in health institutions have significant association with skilled birth attendance. Compared to residents of Bench Maji Zone, residents of Keffa Zone and Jimma Zone are more likely to deliver in health institution with AORs of 8.77 and 2.22 respectively. Orthodox Christians are 2.14 times more likely to deliver in health institutions and Protestants are 3.87 times more likely to deliver in health institutions compared to Muslims. Women whose age is 15-19 years are more likely to deliver in health institutions compared to other age groups. Women whose age is 35 years and above are 77% less likely to deliver in health institutions compared to women whose age is 15-19 years. Those mothers whose wealth index is in the third and fourth quartile respectively were 2.1 and 2.7 times more likely to deliver in health institutions compared to those whose wealth index is in the first quartile. Women who were visited by HEWs at home during pregnancy are 2.39 times more likely to deliver in health institutions compared to those who were not visited by HEWs. Mothers who had ANC visit are about 2.7 times more likely to deliver in health institutions compared to those who had no ANC visit. Those mothers who have good knowledge on the advantages of delivering in health institutions are about 2 times more likely to deliver in health institutions compared to those who have overall poor knowledge (Table 8).

Table 8: Factors associated with skilled birth attendance in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 ______Socio-economic characteristics Skilled birth attendance AOR 95% Confidence interval Yes No Lower Upper N(%) N(%) ______Zone Bench Maji 189(72.1) 73(27.9) Keffa 249(95.0) 13(5.0) 8.77 3.96 19.72 Segen 105(59.7) 71(40.3) 1.06 0.65 1.72 Jimma 257(73.2) 94(26.8) 2.22 0.55 8.44 Religion Muslim 258(73.3) 94(26.7) Orthodox 241(87.0) 36(13.0) 2.14 0.67 6.83 Protestant 284(73.2) 104(26.8) 3.87 1.08 13.90 Other 17(50.0) 17(50.0) 1.30 0.29 5.93 Age of the mother 15-19 80(89.9) 9(10.1) 20-24 248(81.6) 56(18.4) 0.57 0.25 1.27 25-29 258(73.1) 95(26.9) 0.29 0.13 0.63 30-34 147(74.6) 50(25.4) 0.32 0.14 0.73 >=35 67(62.0) 41(38.0) 0.23 0.10 0.54 Wealth index First quartile 163(62.2) 99(37.8) 38

Second quartile 203(77.2) 60(22.8) 1.41 0.90 2.22 Third quartile 215(81.7) 48(18.3) 2.09 1.28 3.41 Fourth quartile 219(83.3) 44(16.7) 2.67 1.55 4.59 HEW visit during pregnancy No 336(66.7) 168(33.3) Yes 464(84.8) 83(15.2) 2.39 1.64 3.48

ANC service utilization No 137(53.3) 120(46.7) Yes 663(83.5) 131(16.5) 2.65 1.82 3.86 Knowledge on the advantages of delivering in health institutions Poor knowledge 548(74.5) 188(25.5) Good knowledge 252(80.0) 63(20.0) 1.95 1.27 3.01

______

5.3.3 Utilization of PNC services

Two hundred ninety nine (28.5%) women reported that they were visited by HDAs at home during the first six weeks after delivery. Overall 439 (41.8%) women received PNC by health professionals at home or health institutions during the first six weeks after delivery. Some women received PNC at more than one site. Three hundred fifty six (81.1%) women received PNC at home by health extension workers, 163(37.1%) at health posts, 152(34.6%) at health centers, and 25 (5.7%) at government hospitals. Overall, 264 women (25.1%) received PNC in public or private health institutions. Out of 439 women who had PNC visit, 175 (39.9%) women received PNC within 48 hours and 306(69.7%) within 72 hours after delivery. Considering the total 1051 women who gave birth in the past one year, 16.7% received PNC within 48 hours and 29.1% received within 72 hours after delivery.

As shown in Table 9, PNC service utilization rate within six weeks of delivery was highest in keffa Zone (86.6%) and lowest in Jimma Zone (17.7%). PNC service utilization was higher in urban areas (64.0%), and maternal age 30-34 years (46.2%).

Table 9: Utilization of PNC services by background characteristics in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Background characteristic Utilized PNC services Yes No Total N(%) N(%) N(%) Zone Bench Maji 92(35.1) 170(64.9) 262(100.0) Keffa 227(86.6) 35(13.4) 262(100.0) Segen 58(33.0) 118(67.0) 176(100.0) SNNP total 377(53.9) 323(46.1) 700(100.0) Jimma 62(17.7) 289(82.3) 351(100.0) Total 439(41.8) 612(58.2) 1051(100.0) Residence Rural 284(35.1) 525(64.9) 809(100.0) Urban 155(64.0) 87(36.0) 242(100.0) Age of the mother 15-19 35(39.3) 54(60.7) 89(100.0) 20-24 120(39.5) 184(60.5) 304(100.0) 25-29 162(45.9) 191(54.1) 353(100.0) 30-34 91(46.2) 106(53.8) 197(100.0) 35-46 31(28.7) 77(71.3) 108(100.0)

Three hundred eighty two (87.0%) and 370(84.3%) respectively reported that the health professionals assessed for vaginal bleeding, and danger signs in the baby during PNC. Two hundred eighty six (65.1%) used post partum family planning methods while 194(44.2%) were supplemented with iron and folic acid. Regarding counselling services, 432(98.4%) were advised about immunization, 430(97.9%) on exclusive breast feeding of the baby until six months of age, and 393(89.5%) on appropriate clothing of the baby for ambient temperature (Table 10).

Table 10: Type of services given to mothers during PNC visit in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Type of PNC service Service given to mothers Total N=439 ’ Yes No Don t know/ Not sure N(%) N(%) N(%) Assessed vaginal bleeding 382(87.0) 35(8.0) 22(5.0) Assessed the baby for danger signs 370(84.3) 52(11.8) 17(3.9) Assessed temperature 256(58.3) 145(33.0) 38(8.7) Checked for uterine tenderness and vaginal discharge 256(58.3) 133(30.3) 50(11.4) Measured blood pressure (BP) 243(55.4) 168(38.3) 28(6.4) Checked healing of perineal or C/S wound 120(27.3) 247(56.3) 72(16.4) Counsel about family planning 401(91.3) 31(7.1) 7(1.6) Used family planning method 286(65.1) 153(34.9) 0(0.0) Provided iron and folic acid supplementation to be used for 194(44.2) 243(55.4) 2(0.5) at least three months after delivery Advised about immunization 432(98.4) 5(1.1) 2(0.5) Advised to exclusively breast feed the baby until 6 months 430(97.9) 5(1.1) 4(0.9) of age Advised on appropriate clothing of the baby for ambient 393(89.5) 29(6.6) 17(3.9) temperature Advised to delay bathing of the baby until 24 hours after 368(83.3) 59(13.4) 12(2.7) birth Advised to apply chlorhexidine ointment on the 93(21.2) 298(67.9) 48(10.9) umbilical cord stump which is to be applied daily during the first 7 days of life

5.3.4 Utilization of NBC services

Overall, 772 (73.5%) newborns received newborn care (NBC) at home by health extension workers and/or health institutions during the first two months after birth. Out of the total 1051 women, 507 (48.2%) women reported that their newborns were visited at home by health extension workers while 566 (53.9%) newborns were taken to the health institutions for care. Out of the 772 newborns who received NBC, 301(39.0%) newborns received care both at home and health institution, 206 (26.7%) received care only at home, and 265 (34.3%) received care only in the health institutions.

As shown in Table 11, NBC service utilization rate was highest in keffa Zone (88.5%) followed by Jimma Zone (72.6%). The service utilization was higher in urban (77.3%) than rural areas (72.31%).

Table 11: Utilization of NBC services by background characteristics in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Background characteristics Utilized NBC Yes No Total N(%) N(%) N(%) Zone Bench Maji 187(71.4) 75(28.6) 262(100.0) Keffa 232(88.5) 30(11.5) 262(100.0) Segen 98(55.7) 78(44.3) 176(100.0) SNNP total 517(73.9) 183(26.1) 700(100.0) Jimma 255(72.6) 96(27.4) 351(100.0) Total 772(73.5) 279(26.5) 1051(100.0) Residence Rural 585(72.3) 224(27.7) 809(100.0) Urban 187(77.3) 55(22.7) 242(100.0) Age of the mother 15-19 66(74.2) 23(25.8) 89(100.0) 20-24 224(73.7) 80(26.3) 304(100.0) 25-29 262(74.2) 91(25.8) 353(100.0) 30-34 146(74.1) 51(25.9) 197(100.0) 35-46 74(68.5) 34(31.5) 108(100.0)

Factors associated with NBC service utilization

Table 12: Factors associated with newborn care services utilization in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017 ______Socio-economic characteristics Utilized NBC AOR 95% Confidence interval Yes No Lower Upper N(%) N(%) ______Religion Muslim 260(73.9) 92(26.1) Orthodox 239(86.3) 38(13.7) 1.36 0.85 2.15 Protestant 255(65.7) 133(34.3) 0.48 0.32 0.71 Other 18(52.9) 16(47.1) 0.40 0.17 0.95 Marital status Currently unmarried 27(64.3) 15(35.7) Currently married 745(73.8) 264(26.2) 2.29 1.1 4.75 HDA home visit during pregnancy No 463(65.8) 241(34.2) Yes 309(89.0) 38(11.0) 2.04 1.34 3.12 HEW home visit during pregnancy No 305(60.5) 199(39.5) Yes 467(85.4) 80(14.6) 3.0 2.03 4.40 ANC service utilization No 130(50.6) 127(49.4) Yes 642(80.9) 152(19.1) 2.28 1.60 3.23 Health institution delivery No 136(54.2) 115(45.8) Yes 636(79.5) 164(20.5) 1.83 1.30 2.58 ______

A total of 85 (8.1%) women reported that their newborns were sick or smaller in size during their first 2 months of life. Out of the 85 newborns that were reported to be sick or smaller in size, 71(83.5%) were having one or more of the symptoms and signs included in the survey questionnaire. While one newborn could have manifested with more than one signs and symptoms, the three commonest diseases/signs and symptoms reported by the mothers were diarrhoea (4.4%), reduced feeding (3.6%), and difficulty breathing/fast breathing (pneumonia) (2.7%). No case of yellow palms/soles/eyes (jaundice) and only 1(0.1%) case of convulsion were reported. Out of the 71 newborns who had symptoms and signs included in the survey questionnaire, 61(85.9%) were treated at home or health institutions. All cases of difficulty breathing/fast breathing with chest in-drawing (severe pneumonia), skin pustules, red cord or pus draining cord, and convulsion were treated at home by HEWs or in the health institutions. Forty (87.0%) of the diarrhoea cases were similarly treated at home or health institutions (Table 13).

Table 13: Newborns treated at home by HEW and health institutions when having health problem in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Health problem N(%) having the N(%) treated by health problem professionals at Total N=1051 home & health institution Diarrhea 46(4.4) 40(87.0) Reduced feeding 38(3.6) 34(89.5) Difficulty breathing/Fast breathing 28(2.7) - Difficulty breathing/Fast breathing + Chest in- 3(0.3) 3(100.0) drawing (Severe pneumonia) Unusually hot or cold 24(2.3) 23(95.8) Less active than usual 10(1.0) 9(90.0) Smaller size 9(0.9) 8(88.9) Skin pustules 6(0.6) 6(100.0) Cord red or draining pus 4(0.4) 4(100.0) Convulsion 1(0.1) 1(100.0) Yellow palms/soles/eyes (Jaundice) 0(0.0) -

5.3.5 Utilization of child care services

Out of the total 921 children whose age is 2 months to less than one year, 116 (12.6%) were reported to be sick during the past two weeks. Ninety five children were having diarrhoea and/or fever and/or pneumonia. From the total 921 children, 42 (4.6%) had diarrhoea, 72(7.8%) had fever, and 32 (3.5%) had pneumonia in the past two weeks. The prevalence of diarrhoea was highest in Segen Zone (14.7%), rural areas (4.8%), and among children whose ’ mother s age is 15-24 years (5.5%). The prevalence of fever was highest in Segen Zone ’ (9.8%), rural areas (8.4%), among children whose mother s age is 35 years and above (9.2%). Similarly, the prevalence of pneumonia was highest in Segen Zone (7.8%), rural areas ’ (3.7%), and among children whose mother s age is 35 years and above (4.6%).

As shown in Table 14, 36 (85.7%) children with diarrhoea, 65 (90.6%) children with fever, and 30(93.8%) children with pneumonia sought care at home by health extension workers and/or health institutions. The percentages of children with diarrhoea who sought care was highest in Bench Maji Zone (100.0%), urban areas (100.0%), and in children whose mothers age is 35 years and above (100.0%). The percentages of children with fever who sought care was highest in Bench Maji Zone (100.0%), urban areas (100.0%), and in children whose ’ mother s age is 25-34 years (92.3%). The percentages of children with pnuemonia who sought care was highest in Bench Maji, keffa and Jimma zones (100.0%), urban areas (100.0%), and in children whose mothers age is 15-24 and 35 years and above (100.0%).

Table 14: Children 2 months to less than one year treated at home by HEW and health institutions when having health problem in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Background Total Diarrhoea Fever Pneumonia characteristics number N (%) N(%) with N (%) N(%) with N (%) N(%) with of having the problem having the having the problem children the treated by the problem the treated by 2 problem professionals proble treated by problem professionals months at home & m professiona at home & to <1 health ls at home health year institutions & health institutions institutions Zone Bench Maji 247 11(4.5) 11(100.0) 20(8.1) 20(100.0) 5(2.0) 5(100.0) Keffa 248 8(3.2) 7(87.5) 12(4.8) 10(83.3) 4(1.6) 4(100.0) Segen 102 15(14.7) 11(73.3) 10(9.8) 8(80.0) 8(7.8) 6(75.0) Jimma 324 8(2.5) 7(87.5) 30(9.3) 27(90.0) 15(4.6) 15(100.0) Total 921 42(4.6) 36(85.7) 72(7.8) 65(90.3) 32(3.5) 30(93.8) Residence Rural 703 34(4.8) 28(82.4) 59(8.4) 52(88.1) 26(3.7) 24(92.3) Urban 218 8(3.7) 8(100.0) 13(6.0) 13(100.0) 6(2.8) 6(100.0) Total 921 42(4.6) 36(85.7) 72(7.8) 65(90.3) 32(3.5) 30(93.8) Age group 15-24 348 19(5.5) 16(84.2) 25(7.2) 23(92.0) 9(2.6) 9(100.00) 25-34 486 20(4.1) 17(85.0) 39(8.0) 36(92.3) 19(3.9) 17(89.5) 35+ 87 3(3.4) 3(100.00) 8(9.2) 6(75.0) 4(4.6) 4(100.0) Total 921 42(4.6) 36(85.7) 72(7.8) 65(90.3) 32(3.5) 30(93.8)

5.3.6 Conclusion and recommendation on utilization of MNCH services Conclusion ANC service utilization and health institution delivery rates are higher than EDHS 2016 report and the targets set by UNICEF-KOICA MNCH project at the end of 2018 but the percentage of mothers who received PNC within 72 hours is much lower (29.1%) than the target set by UNICEF-KOICA MNCH project (75.0%). The percentages of newborns with the health problems that were treated at home or health institutions are already higher than the target set by UNICEF-KOICA MNCH project. Similarly, higher percentages of children with ARI, fever and diarrhoea were treated by health workers compared to the findings of EDHS 2016. Considering modifiable risk factors, home visit by HEWs during pregnancy positively influenced ANC, health institution delivery, and NBC. Availability of family health card in the house also has a positive effect on utilization of ANC services. Additionally, ANC service utilization, knowledge on the advantages of delivering in health institutions are the factors that have an effect on health institution delivery. Home visit by HDAs, ANC service utilization, and health institution delivery also positively influence the utilization of NBC services

Recommendation While continuing the current effort in implementation of the interventions, more emphasis need to be given for PNC as the coverage is far from the target. Awareness creation and motivation of the mothers to use MNCH services need to be strengthened by using different strategies like availing family health card, home visit by HDAs and HEWs.

’ 5.4 Findings related to Objective 3: Assess mothers perceived quality of high impact MNCH services in the project intervention areas.

5.4.1 Quantitative findings from household survey related to quality of MNCH services

Nine questions related to perceived quality of MNCH services were asked. Seven hundred ninety four women who had ANC visit in health institutions were interviewed regarding how much they were satisfied with the service they received. Seven hundred seventy seven (97.9%) have favourable perception on the quality of ANC services provided to them. In SNNP Region 490 (97.2%) have favourable perception and in Jimma Zone of Oromia Region 287(99.0) mothers have favourable perception. Similarly, 785 (98.1%) women have favourable perception on the quality of delivery services. All the 257 women in Jimma Zone of Oromia Region and 528 (97.2%) women in SNNP Region have favourable perception on the quality of delivery services. Two hundred sixty four women who had PNC care at health institutions were interviewed about their perception on the quality of PNC services. Two hundred fifty (94.7%) have favourable perception on the quality of PNC care given in the health institutions including health posts. In SNNP 205 (94.0%) women have favourable perception and in Jimma Zone of Oromia Region 45(97.8%) have favourable perception on the quality of PNC services given in the health institutions (Table 15). 48

Perceived quality of the 61 women who had brought their sick newborns to health institutions was assessed. Overall, 51(83.6%) women have favourable perception on the quality of NBC services given in health institutions. All the five women in Jimma Zone of Oromia Region and 46(82.1%) women in SNNP Region have favourable perception on the quality of NBC service in health institutions. The perception of 83 mothers who had brought their sick children age 2 months to less than one year old to health institutions was also assessed. Seventy nine (92.9%) women have favourable perception on the quality of child care services in the health institutions. In SNNP and Jimma Zone of Oromia Region, 44(89.8%) and 33(97.1%) respectively have favourable perception (Table 15).

Table 15: Perception of mothers on the quality of MNCH services in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Component Bench Maji Keffa Segen SNNP total Jimma Zone All the 4 zones of MNCH Total Have Total Have Total Have Total Have Total Have Total Have service number of favourable number of favourable number of favourable number of favourable number of favourable number of favourable mothers perception mothers perception mothers perception mothers perception mothers perception mothers perception interviewed on the interviewed on the interviewed on the interviewed on the interviewed on the interviewed on the on the quality of on the quality of on the quality of on the quality of on the quality of on the quality of quality of the service quality of the service quality of the service quality of the service quality of the service quality of the service the N(%) the N(%) the N(%) the N(%) the N(%) the N(%) service* service* service* service* service* service* ANC 192 191(99.5) 242 231(95.5) 70 68(97.1) 504 490(97.2) 290 287(99.0) 794 777(97.9) Delivery 189 187(98.9) 249 237(95.2) 105 104(99.0) 543 528(97.2) 257 257(100.0) 800 785(98.1) care PNC 26 26(100.0) 151 138(91.4) 41 41(100.0) 218 205(94.0) 46 45(97.8) 264 250(94.7) NBC 2 1(50.0) 11 11(100.0) 43 34(79.1) 56 46(82.1) 5 5(100.0) 61 51(83.6) Child care 21 20(95.2) 16 15(93.8) 12 9(75.0) 49 44(89.8) 34 33(97.1) 83 77(92.8) * Those mothers who visited health institutions for the service were interviewed about quality

When different parameters of perception are considered, good perception rates on the quality of different MNCH services ranged from 72.1% to 97.6%. Generally, high perception/satisfaction rates across the MNCH components were reported for privacy when receiving the service, maintaining confidentiality of information, and equal treatment of every woman when visiting health institutions for MNCH services. Regarding privacy when receiving MNCH services, 766 (96.5%) mothers have favourable perception when receiving ANC care, 781 (97.6%) when delivering in health institutions, 254 (96.2%) when receiving PNC, 50(82.0%) when receiving NBC, and 76 (91.6%) when receiving child care. Similarly, high percentage of mothers have favourable perception on maintaining confidentiality of information when receiving ANC care (96.6%), when delivering in health institutions (97.6%), when receiving PNC (95.1%), when receiving NBC (73.8%), and when receiving child care (91.6%). Relatively, mothers are less satisfied with the presence and cleanness of ’ latrines. Related to mothers satisfaction on the presence and cleanness of latrines, 692 (87.2%) mothers had favourable perception when receiving ANC, 670(83.8%) when receiving delivery care, 204(77.3%) when receiving PNC, 46(75.4%) when receiving NBC, and 62(74.7%) when receiving child care. Mothers are also less satisfied with the affordability of services including drugs and other supplies when receiving NBC and child care services. Forty four (72.1%) mothers who received NBC and 72(86.7%) mothers who received child care were satisfied with the affordability of services including drugs and other supplies which is lower compared to other parameters which make up quality of MNCH services (Table 16).

Table 16: Perception of mothers on the quality of different MNCH services in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Perception/Satisfaction parameters ANC Delivery PNC NBC Child Care Care N(%) with N(%) with N(%) with N(%) with N(%) with favourable favourable favourable favourable favourable perception perception perception perception perception Total Total Total Total Total N=83 N=794 N=800 N=264 N=61 Satisfaction with the privacy when receiving care 766(96.5) 781(97.6) 254(96.2) 50(82.0) 76(91.6) Satisfaction with maintaining confidentiality of the information 767(96.6) 781(97.6) 251(95.1) 45(73.8) 76(91.6) Satisfaction with the service providers in treating every woman 763(96.1) 780(97.5) 248(93.9) 47(77.0) 75(90.4) equally Satisfaction with the competence of providers 761(95.8) 780(97.5) 248(93.9) 47(77.0) 76(91.6) Satisfaction with the affordability of the services including 771(97.1) 775(96.9) 251(95.1) 44(72.1) 72(86.7) drugs & other supplies Satisfaction with the courteousness/friendliness of service 758(95.5) 774(96.8) 243(92.0) 47(77.0) 77(92.8) providers Satisfaction with the information given by health care 752(94.7) 775(96.9) 240(90.9) 47(77.0) 76(91.6) providers Satisfaction with the waiting time 750(94.5) 769(96.1) 225(85.2) 47(77.0) 75(90.4)

Satisfaction with the presence & cleanness of latrines 692(87.2) 670(83.8) 204(77.3) 46(75.4) 62(74.7)

5.4.2 Qualitative findings related to quality of MNCH services

5.4.2.1 Quality of MNCH services in the health posts

Among other services, health posts provide ANC, PNC, CBNC, and ICCM services. Their role on awareness creation of the community, together with the health development armies is appreciated by the informants. They provide services in the health post and by going home to home. While they are trying their best to provide quality MNCH services, there are several obstacles to accomplish their tasks as reported by the participants of qualitative study. The problem starts with the physical condition of the health posts and absence of health post which is constructed for that purpose. One kebele administrator from Dedo Woreda of Jimma Zone reported that there is no health post constructed for the purpose of providing health ’ service. Since the construction of the health post couldn t be finished, the kebele gave them some rooms to serve as health post which is not convenient to provide the services. One of the health extension workers in Amaro Woreda of Segen Zone also expressed her concern of “ the physical condition of the health post as ...But, the major problem is the health post is very old and started to fall down. It is even scary for me to be inside the health post alone. Even I am afraid of snakes in the health post. Unless clients come to the health center, I will ’ not go inside. Every time I clean the room but immediately it gets dirt..... I can t even keep the ORS cups and materials clean. There is opening at the back wall. Kids enter to the room ” and play and break some important equipment . The other problem reported was that community settlement is scattered that visiting houses is tiresome for the health extension workers.

The standard with regard to the number of health extension workers in each health post is two. In some health posts, only one health extension worker is currently working. Even in health posts where two health extension workers are assigned, health posts are closed when both are unavailable for different reasons like attending meetings, trainings etc. There is common understanding by the participants of the qualitative study that the number of health extension workers shall increase in each health post.

CBNC and ICCM are started in the health posts which are very important for newborns and children. Shortage of drugs like gentamycin, zinc, iron is reported by most informants. People are being obliged to buy drugs from private pharmacies which are expensive. Shortage of equipments and supplies is also affecting quality of services in the health posts. There are health extension workers who reported lack/shortage of BP apparatus, weight scale, and height measurement board. Participants from the community also reported the inadequacy of ITNs distributed to each household. Shortage of supplementary foods for malnourished children is also raised.

Health extension workers also reported their need for different trainings. For example, two health extension workers from Keffa and Segen zones mentioned the need for training on “ family planning. A health extension worker from Segen Zone said We are trained on how to ’ insert implanon but not how to remove it. So, the women complain that why you can t ” remove what you have inserted? . There is no also strong supervision of the health posts by staff at health center level, according to the informants.

5.4.2.2 Quality of MNCH services in the health centers

The number of people utilizing the services in the health centers is increasing. Mothers also want all services given in the health centers including C/S. Most participants feel that relatively good quality service is provided in the health centers. On the other hand, shortage of staff; shortage of some services; shortage of equipment, drugs, and supplies; shortage of trainings; shortage of rooms; shortage of water and electricity; and inappropriate behaviours of health professionals are mentioned as some of the obstacles which affect quality of services in the health centers.

The health center staffs mentioned that the number of clients and number of staff working in the health centers are not proportional. They feel that they are overstretched. An informant from one of the health centers in Jimma Zone emphasized the shortage of staff in the health “ centers by saying .. A health worker provides delivery service during the night and continues ” providing ANC and PNC services during the day . Since, health centers have shortage of staff, they reported that health professionals most of the time do not accompany labouring mothers when they are referred to the hospitals. In addition to shortage of staff in general, most of the staff are newly assigned without experience. Hence, they emphasized giving in- service training to these newly assigned staff. The staffs expressed their need for training on different services like BEmONC, CEmONC, ANC, PMTCT, family planning, EPI, delivery etc.

Lack or shortage of laboratory services in the health centers was mentioned both by the professionals at the health centers and clients. An informant from one of the health centers in “ Meinit Goldeya Woreda, Bench Maji Zone said There is no laboratory service in the health center so that we usually refer mothers for simple laboratory tests. Mothers are suffering from ” being referred to hospitals for laboratory services . In the same zone, an informant from “ woreda health office expressed the seriousness of the problem by saying ..With regard to maternal health services, laboratories are not functional. Two out of seven health centers in the woreda are providing laboratory services including haemoglobin and syphilis test for pregnant women during ANC. There is shortage of laboratory professionals as well as ” reagents . Another informant from woreda health office in Keffa Zone reported that they have no laboratory professional in 3 health centers.

Shortage of drugs at the health centers is mentioned both by health center staff and clients. Since, drugs are not available in the health centers, mothers are obliged to buy the drugs at private pharmacies. The mothers also complained that drugs at the private pharmacies are expensive.

Clients are not also happy with the behaviour of some health professionals in the health centers. Some of them are not friendly to clients. Some are not available in the health center during working hours.

Shortage of water in the health centers was mentioned as major obstacle in the health centers to keep rooms and equipment clean. The lack of cleanness of delivery rooms and delivery couch is mentioned by mothers. One of the reasons could be lack of water. Similarly, lack of or frequent interruption of electricity is reported as a problem by health professionals at the health center to effectively perform their tasks.

5.4.2.3 Quality of MNCH services in the primary hospitals

Most informants reported that good quality MNCH service is given in the primary hospitals. ’ But, this doesn t mean everything is complete in the primary hospitals. Informants from the primary hospitals complained that there is shortage of staff. This shortage creates dissatisfaction on clients due to longer waiting time. This is also reported by mothers and kebele administrators. The need for staff training on topics like CEmONC, BEmONC, ANC, PMTCT, EPI, safe abortion etc was also raised. One of the hospitals in Segen Zone is not also providing blood transfusion service. Lack of rooms, equipment, drugs and other supplies in the primary hospitals is also raised. Like the health centers, there is shortage of water and interruption of electricity in the primary hospitals as reported by informants from the hospitals.

5.4.3 Conclusion and recommendation on the perceived quality of MNCH services Conclusion Generally, high percentage of mothers who visited health institutions has favourable perception on the quality of MNCH services. The main problems that affect quality include unavailability of services like laboratory services in health centers; lack of drugs, supplies, equipment; shortage of skilled manpower; shortage of rooms; lack of water and electricity; shortage of ambulances when referral is needed.

Recommendation The responsible bodies need to avail the services, drugs, supplies, and equipment. Adequate number of health professionals need to be assigned in health institutions at different levels and providing trainings on different MNCH services has to be considered. Infrastructures like electricity and water need to be fulfilled to provide quality MNCH service.

5.5 Findings related to Objective 4: Explore the demand for high impact MNCH services - ANC, SBA, ICCM, CBNC, Newborn Corner, NICU, and BEmONC.

5.5.1 Quantitative findings regarding the demand for MNCH services

Generally, mothers have the feeling that more women are seeking ANC and delivery care in health institutions. Eight hundred eighty two (83.9%) women expressed their feeling that more women are seeking ANC care in health institutions and 890 (84.7%) feel that more women are delivering in the health institutions. On the other hand, only 659(62.7%) women feel that more women are seeking PNC in health institutions. Similarly, 819(77.9%) of the women feel that families are seeking NBC in health institutions and 826 (78.6%) feel that families are seeking child care in health institutions. While 799(76.0%) women agreed that more women are seeking ANC in health posts, only 617(58.7%) feel that more women are seeking PNC in the health posts. Similarly, 737(70.1%) and 657(62.5%) respectively have the feeling that more families are bringing their children to the health posts for NBC and child care. High percentage of women (79.6%) have the thought that there is more demand for delivering in health centers but the demand for PNC (53.3%), NBC (67.3%), and child care 55

(68.8%) in health centers is relatively lower. Less than 45% of the mothers feel that there is demand for MNCH services in the primary hospitals (Table 17).

Table 17: Demand for MNCH services in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Demand statement Level of agreement ANC Delivery PNC NBC Child care care More women are seeking Agree 882(83.9) 890(84.7) 659(62.7) 819(77.9) 826(78.6) care at health facilities Indifferent 157(14.9) 145(13.8) 320(30.4) 206(19.6) 218(20.7)

Disagree 12(1.1) 16(1.5) 72(6.9) 26(2.5) 7(0.7) More women are seeking Agree 799(76.0) - 617(58.7) 737(70.1) 657(62.5) care at the nearby health post Indifferent 174(16.6) - 347(33.0) 244(23.2) 284(27.0) Disagree 78(7.4) - 87(8.3) 70(6.7) 110(10.5) More women are seeking Agree 787(74.9) 837(79.6) 560(53.3) 707(67.3) 723(68.8) care at the nearby health Indifferent 209(19.9) 180(17.1) 378(36.0) 269(25.6) 294(28.0) center Disagree 55(5.2) 34(3.2) 113(10.8) 75(7.1) 34(3.2) More women are seeking Agree 384(36.5) 464(44.1) 294(28.0) 314(29.9) 342(32.5) care at the nearby primary Indifferent 398(37.9) 404(38.4) 492(46.8) 482(45.9) 475(45.2) hospital Disagree 269(25.6) 183(17.4) 265(25.2) 255(24.3) 234(22.3)

5.5.2 Qualitative findings regarding the demand for MNCH services

Informants from all zones mentioned that utilization of maternal, newborn and child health services is increasing from time to time. Even though the overall demand for maternal, newborn, and child health services has increased, the utilization of delivery services and family planning is relatively low. Lack of accessible health centers and culture have major role for low utilization of delivery services in health institutions, according to the informants. Since health posts are not providing delivery service, women have to travel long distance to give birth in the health centers. Reaching the health centers has been reported to be difficult in remote areas which have no access to road. In addition, shortage of ambulances is mentioned as a major problem in all zones that taking labouring mother to health centers is difficult. Pregnant women from remote areas are advised to stay in the maternity waiting rooms when they are near term. But maternity waiting rooms are either not available in the health center or facilities in the maternity waiting rooms are limited that mothers may not be interested to stay in the maternity waiting rooms. Additionally, it was mentioned that the ’ mothers commitment at home will not allow them to stay in the maternity waiting rooms for days or weeks. Some husbands are not also supportive of this idea as mentioned by most of the participants.

5.5.3 Conclusion and recommendation on the demand for MNCH services Conclusion Generally there is demand for seeking MNCH services in health institutions but the demand for PNC seems low. Demand for delivery service in health institutions is also low in some communities like pastoralists. Among other things, cultural influences have an effect on utilization of MNCH services like PNC, delivery, and family planning. Communities request to have delivery services near their home. Recommendation Awareness creation on different MNCH services and availing the services in accessible places need to be considered. Influential people in the community need to be involved in the advocacy, communication, and social mobilization.

5.6 Findings related to Objective 5: Examine the actual referral linkage process and mechanisms in place for Maternal and newborn cases within the primary care units/delivery platform

5.6.1 Quantitative findings related to referral linkage

A total of 330 women or children were referred to higher level health institution for better management of the cases. Most of them were referred from health post to health center (63.6%), and from health center to primary hospital (28.5%). Out of the total 330 referred mothers and children, 320 (97.0%) managed to go the referral sites. Mothers and children used ambulance and cars/bajajs equally (122 each) to go to the referral site. Ambulances were the major means of transport when labouring mothers were referred to the higher level health institutions. Sixty eight (59.6%) of the mothers in labor were taken by ambulance when referred to the next level health institution. In other circumstances, private cars or bajajs were used to take the mothers and children to the referral sites. Thirty seven (11.6%) mothers were taken by traditional ambulance when they were referred during pregnancy, labor, and post partum period. Thirty nine (12.2%) of the referred mothers went or take their children to the referral sites by walking (Table 18)

Table 18: Referral process in Segen, Kefa and Bench Maji of SNNP Region, and Jimma Zone of Oromia Region, March 2017

Period Numb Referral link Managed to Means of transport when going to the referral site er HP to HC HC to PH HC to PH to HC to HP to PH go to Ambulance Car/Bajaj Tradition Walking referr N(%) N(%) GH GH SH N(%) referral site N(%) N(%) al N(%) ed N(%) N(%) N(%) N(%) ambulanc e N(%) Pregnancy 183 148(80.9 31(16.9%) 1(0.5%) 3(1.6%) - - 175(95.6%) 48(27.4%) 76(43.4%) 20(11.4%) 31(17.7%) %) Labor/delivery 115 43(37.4%) 56(48.7%) 7(6.1%) 2(1.7%) 6(5.2%) 1(0.9%) 114(99.1%) 68(59.6%) 30(26.1%) 12(10.5%) 4(3.5%) Post partum 16 11(68.8%) 3(18.8%) 2(12.5%) - - - 16(100.0%) 5(31.3%) 6(37.5%) 5(31.3%) - (Maternal care) Newborn from birth 7 3(42.9%) 2(28.6%) 2(28.6%) - - - 7(100.0%) - 5(71.5%) - 2(28.6%) to < 2 months Child from 2 9 5(55.6%) 2(22.2%) 2(22.2%) - - - 8(88.9%) 1(12.5%) 5(62.5%) - 2(25.0%) months to < 1 year Total 330 210(63.6) 94(28.5% 14(4.2%) 5(1.5%) 6(1.8%) 1(0.3%) 320 122(38.1%) 122(38.1%) 37(11.6% 39(12.2%) ) (97.0%) )

HP- Health post, HC-Health center, PH-Primary hospital, GH-General hospital, SH-Specialized hospital

Nine women who managed to go to the next level health institution during pregnancy reported that they faced problems before and after arriving to the referred health institutions. The reported problems were the ambulance arrived lately by three women (33.3%), the amount I paid for the transportation was too much by three women (33.3%), and the next level health institution was too far by two women (22.2%). Eight referred women during ’ pregnancy didn t go to the referred health institution their main reasons being no vehicle to lease by 3 women (37.5%), no ambulance by 2(25%) women, and no sufficient money to lease a car/bajar by 1(12.5%) woman.

Twelve (10.4%) women who managed to go to the next level health institution during labor reported that they faced problems before and after arriving to the referral health institution. The reported problems were the ambulance arrived lately by seven women (58.3%), the amount I paid for transportation was too much by three women (25.0%), the next level health institution was too far by one woman (8.3%), and there was no one who can accompany her ’ by one woman (8.3%). One woman didn t go to the referred health institution her reason being there was no one who can accompany her.

5.6.2 Qualitative findings related to referral linkage process

The HDAs visit each house to teach mothers about MNCH services. They also identify women and children who shall go to the health posts for different services. The health extension workers also visit houses and give services there like postnatal care, newborn care etc. At the health post, the HEWs provide different MNCH services except delivery. The formal referral linkage is from health post to health center to primary hospital to general hospital and finally to specialized hospital. According to the informants of the qualitative study, this referral sequence is respected in most circumstances.

Health extension workers follow pregnant women and finally advise them to go to the health center, usually at the 8th month of pregnancy for further assessment by professionals at the health center. The professionals at the health centers may advise the mother to stay in the maternity waiting rooms if she lives far from the health center. Families use different means of transportation to go to the health institutions. Mothers and children who have no access for transportation have to walk to reach to the health institutions or have to be carried by people, if they are unable to walk like during labor. If there is access to road, they have two options to go to the health institutions. During emergency situations like labor and critical illness, ambulances can be called to take the mother and children to the health institutions. But, getting ambulance service is difficult in most places as reported by different participants. In such circumstance, they have to use public transport or lease vehicles. Ambulances are stationed at woreda level except in Jimma zone where they have reported that two ambulances are stationed in remote health centers. The number of ambulances ranged from one to five per woreda. Jimma Zone has relatively better number of ambulances per woreda compared to other zones.

If labouring mothers are referred to hospital by health center staff, usually ambulances are used to take them. Some woredas also use other cars owned by the woreda to transport mothers when referred by health centers. This happens in circumstances when ambulances are unavailable. If there is a need for primary hospitals to refer mothers to general and specialized hospitals, the primary hospitals use their ambulances.

When mothers, newborns, and children are critically sick, they are entitled to use ambulances but due to shortage of ambulances, other transportation means are usually used. In areas like Amaro Woreda of Segen Zone, since other vehicles are short, motorcycles are also used to transport sick children with their mothers.

5.6.3 Conclusion and recommendation on the referral linkage process

Conclusion

Most of the referred mothers and children go to the referral sites with difficulties. The major challenges include inaccessibility of roads, shortage of ambulances, and high transportation cost when using transportation means other than ambulances.

Recommendation

Availing the services close to the community is necessary to reduce the number of referrals. Re-mandating the health posts to provide delivery services with appropriate training and availing of the necessary facilities and equipments may be considered. Additionally, the health centers should be supported so that they can do the necessary investigations and provide the necessary services including emergency obstetric service to reduce referral to hospitals.

5.7 Findings related to Objectives 6,7, and 8: Availability and quality of high impact MNCH services, MNCH equipment, drugs and supplies.

The facility level baseline survey focussed on determining the overall readiness of HPs, HCs and Primary Hospitals to provide the selected high impact MNCH services (ANC, SBA, PNC, NBC, CBNC, NICU and ICCM/IMNCI) which is the important component of health service quality assessment based on the Donabedian Framework. The survey has collected data on the location of the facilities in relation to the referral centre, staffing, training, facility structure, referral support, the availability and accessibility of the selected MNCH services, availability of equipment, drugs, supplies, guidelines, job aids and recording and reporting formats in the four program zones in the two regions. The general hospitals in the zones were included to assess the NICU services only. In addition activities like demand creation and supportive supervision were looked. The survey has included 103 facilities (47 HPs, 48 HCs, 6 primary hospitals and 2 general hospitals).

5.7.1 Results of health post (HP) assessment

5.7.1.1 Distribution of surveyed health posts by zone and woreda

A total of 47 health posts (32 from the three zones in SNNP and 15 from Jimma zone in Oromia) were assessed in this baseline survey (Table 19). Of the surveyed HPs, 37 (78.7%) HPs are located at an approximate distance of 20 or more kilometres from the referral HC. Table 19: Distribution of surveyed health posts by zone and woreda in SNNP and Oromia Regions; UNICEF/KOICA Baseline survey, March 2017

Region Zone Woreda Number of HPs assessed SNNP Bench Maji Meinit Goldia 4 Shebench 4 South Bench 4 Keffa Chena 4 Gimbo 4 Tello 4 Segen Amaro 4 Konso 4 Oromia Jimma Dedo 3 Gomma 4 Mana 4 Sokrou 4 Total 47

5.7.1.2 Staffing of the HPs

There were a total of 77 HEWs (44 Level III and 33 Level IV) in the 47 HPs which is short by 17(18.1%) HEWs compared to the national standard of 2 HEWs per HP. Of the 47 HEWs interviewed, 32 (68.1%) have served for 7 or more years. and 41 (87.2%) were residing in the kebele.

5.7.1.3 Facility Structure and Referral Services

Assessment of the room setup in the HPs revealed that 40 (85.1%) were well lit for day time activity, 39 (83%) were ventilated with at least one open window, 31(66%) provided visual privacy, 28 (59.6%) provide auditory privacy. Only 4 (8.5%) had running water in the room, 2 (4.3%) had hand washing basin, 12 (25.5%) had soap for hand washing, and 10 (21.3%) had alcohol based hand sanitizer. The main sources of water were protected spring for 18 (38.3%), public standpipes for 6 (12.8%), protected dug wells for 5 (10.6%), and surface water for 5 (10.6%). Regarding electric power source, 25 (53.3%) had no electric power source, 16 (34%) had solar panel and 5 (10.6%) had connection to an electric grid. Thirty nine (83%) HPs had hygienic toilets accessible to facility users. Twenty one (44.7%) of the HPs had access to cell phone signal and in 46 (97.9%) HPs staff used their own mobile phone to communicate with other facilities. Only one facility had motorized transport (motorbike) for referral use, but 38 (80.9%) HPs have access to ambulance for transporting referred patients. In 28 (59.6%) HPs the ambulance reaches within 30 minutes after a call is made. Most (93.6%) HPs usually refer their clients to the designated referral health center (Table 20).

Table 20: Facility structure and referrals the HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Source of drinking water Number Percent (Total N=47) Protected springs 18 38.3 Public standpipes 6 12.8 Protected dug wells 5 10.6 Surface water 5 10.6 Piped connection into house 4 8.5 Unprotected spring 3 6.4 Boreholes 2 4.3 Open dug well 2 4.3 Bottled water 1 2.1 Other (specify) 1 2.1 Source of Electricity None 25 53.2 Solar Panel 16 34.0 Electric Grid 5 10.6 64

Other (Specify) 1 2.1

Facility of usual referral Health center 44 93.6 Primary Hospital 3 6.4 Means of communication Facility landline or mobile 1 2.1 phone Staff mobile phone 46 97.9 Structure and referral Hygienic toilets accessible for 39 83.0 users Access to ambulance 38 80.9 Cellphone signal 21 44.7 Motorized transport for referral 1 2.1

5.7.1.4 Maternal health services

5.7.1.4.1 Antenatal and postnatal care services

ANC service was available in 44 (93.6%) HPs. Twenty six (55.4%) HPs provided ANC for 5 days a week, 6 (13.6%) 2 days a week, and 5 (11.4%) provided 3 days a week. Thirty three (75.0%) facilities were open for 8 hours during a typical working day. ANC service was provided both by level III and level IV HEWs and 30 (68.2%) HPs have staff who received integrated refresher training. ANC waiting area was available in 19 (43.2%) HPs. Forty (85.1%) HPs provided PNC services out of which 18 (45%) HPs are open 5 days a week to provide the service and in 9 (22.5%) HPs the service is available 7 days a week. Twenty seven (67.5%) HPs provide PNC service for 8 hours during a typical working day. 5.7.1.4.2 Demand for ANC and PNC

As reported by HEWs, the reasons for seeking ANC services were referral of pregnant women by HDAs mentioned by 32 (72.7%) HEWs, self-referral by 6 (13.6%), and referral by HEWs during routine home visit mentioned by 5 (11.4%) HEWs. With regard to demand for postnatal care, the HEWs in 19 HPs (47.5%) said most women come for PNC visit following referral by HEWs during routine home visits. Nine (22.5%) HEWs said referral by HDAs as the main driver for PNC visit. 5.7.1.4.3 Services provided to pregnant and postnatal women

All HPs providing ANC services advise pregnant women on BPCR. In addition, all HPs with ’ ANC and PNC services counsel women on breast feeding and women s nutrition. Forty three (97.7%) HPs provided family planning counselling during ANC compared to 37 (92.5%) that provide family planning counselling during PNC. BP measurement is done more in pregnant 65

women than in postpartum women, 90.9% and 82.5% respectively. Similarly, weight measurement is done more to pregnant women (84.1%) than to postpartum women (67.5%). De-worming is done in 20 (45.5%) HPs during ANC and only in 11(23.4%) HPs during PNC. Very few HPs said they provide HIV testing during ANC and PNC, 4 (9.1%) and 3 (7.5%) respectively. Only 23 (57.5%) HPs give Vitamin A to postpartum women (Table 21).

Table 21: Status of Services Provided to Pregnant women at HP level, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

ANC PNC Yes No Yes No Services N( %) N( %) N( %) N(%) BF counselling 44(100) 0(0.0) 40 (100) 0 (0.0) Nutrition counselling 44 (100) 0 (0.0) 40 (100) 0 (0.0) Advise on BPCR 44 (100) 0 (0.0) FP counselling 43 (97.7) 1 (2.3) 37 (92.5) 3 (7.5) Immunization 42 (95.5) 2 (4.5) 38 (95.0) 2 (5 .0) BP measurement 40 (90.9) 4 (9.1) 33 (82.5) 7 (17.5) Weight measurement 37 (84.1) 7 (15.9) 27 (67.5) 13 (32.5) Iron or Iron/folic acid provision 31 (77.5) 9 (22.5) 31 (77.5) 9 (22.5) De worming 20 (45.5) 24 (54.5) 11 (23.4) 29 (72.5) PMTCT service (any) 7 (15.9) 37 (84.1) 6 (15.0) 34 (85.0) HIV test 4 (9.1) 40 (90.9) 3 (7.5) 37 (92.5) Vitamin A supplementation 23 (57.5) 17 (42.5)

5.7.1.5 Child health services

– Assessment of child health services included services given to infants 0 2 months and children 2 months to 5 years. – 5.7.1.5.1 ICCM (2 59 months)

– Forty four (93.6%) HPs reported that they were treating children 2 59 months old. In 23 (52.3%) HPs services were available 5 days a week, in 10 (22.7%) 7 days a week, in 5 (11.4%) 3 days a week, and in 3 (6.8%) HPs 2 days a week. During a service day, 41 (93.2%) HPs provide the service both in the morning and in the afternoon. Except for management of acute malnutrition, most iCCM services were provided in the majority of the HPs (Table 22).

Table 22: Status of iCCM services at HP level, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Yes No Treatment/managements N( %) N( %) Cough or difficult breathing 44 (100) 0 (0.0) Diarrhea with dehydration 42 (95.5) 2 (4.5) Malaria 37 (84.1) 7 (15.9) Fever 43 (97.7) 1 (2.3) Severe acute malnutrition 22 (50.0) 22 (50.0) Moderate acute malnutrition 25 (56.8) 19 (43.2) Immunization 44 (100) 0. (0.0) Vitamin A supplementation 42 (95.5) 2 (4.5) Deworming 40 (90.9) 44 (9.1)

5.7.1.5.2 Community Based Newborn Care

Of the 47 HPs, 42 (89.4%) were engaged in providing CBNC services and of these 30 (71.4%) started providing the service before March 2016. Eleven (26.2%) HPs started the service in or after March 2016. As per the report of the HEWs interviewed, in 36 (76.6%) HPs the CBNC program was supported by NGOs in addition to the government support. In 6 (14.3%) HPs the program was supported by government only. Of the 42 HP that provide CBNC, 24 (57.1%) said they provide the service whenever it is needed including the weekends. Twenty nine (69.0%) HPs reported that they have managed – infants 0 2 months in the last 3 months and 21 (72.4%) HPs have referred infants for very sever disease (Table 23).

Table 23: CBNC activities performed at HP level, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Yes No Treatment/managements N(%) N(%) HP staff trained on CBNC 41 (87.2) 6 (12.8) – Facility treated infants 0 2 months old in the last 3 months 29 (69.0) 13 (31.0) CBNC service provided 24/7 24 (57.1) 18 (42.9) – Facility referred infants 0 2months for Very Severe Disease in the last 3 months 21 (72.4) 8 (27.6) HEW provided immediate newborn care in the last 3 months 14 (48.3) 15 (51.7) – Facility treated infant 0 2 months with Gentamycin injection for sepsis 12 (41.4) 17 (58.9) HEW did prevention of hypothermia in the last 3 months 6 (20.7) 23 (79.3) HEW managed hypothermia in the last 3 months 4 (13.8) 25 (86.2) HEW resuscitated a newborn baby in the last 3 months 4 (13.8) 25 (86.2) HEW applied chlorohexidine on the cord in the last 3 months 2 (6.9) 27 (93.1) HEW managed neonatal sepsis and Very Severe Disease at community level in the last 3 months 2 (6.9) 27 (93.1) HEW managed preterm and low birth weight neonates in the last 3 months 1 (3.4) 28 (96.6) HEW did initial stimulation of a newborn with asphyxia in the last 3 months 0 (0.0) 29 100)

5.7.1.6 Training of HP staff on MNCH 5.7.1.6.1 Training on maternal health A total of 63 (36 Level III and 27 Level IV) HEWs from 35 (74.5%) HPs have received refresher training on MNCH as part of IRT. HEWs from 19 (54.2%) HPs received the refresher training in or after March 2016. 5.7.1.6.2 Training on iCCM ICCM trained staff were available in 42 (89.4%) HPs and of the total 77 HEWs, 59 (76.6%) were trained. Close to 90% of the trainings were conducted before March 2016. 5.7.1.6.3 Training on CBNC Forty one (87.2%) HPs have staff trained on CBNC and 17 (41.5%) said they received the training in or after March 2016 5.7.1.6.4 Refresher Training In 35 (74.5%) HPs, staff have received refresher training on MNCH and HEWs from 19 (54.2%) HPs received the refresher training in or after March 2016. Overall three-fourth of staff said they were satisfied with the training they received.

5.7.1.7 Equipment, supplies and drugs at HP level

5.7.1.7.1 Availability of equipment and supplies

Table 24 shows availability of equipment and supplies at HP level. Forty five (95.7%) HPs had MUAC tape, 44 (93.6%) HPs had clinical thermometer, and 41 (87.2%) HPs had fetoscope. Least available supplies and equipment were washable mackintosh (4.3%), penguin section bulb (6.3%), face mask (10.6%), soap and towel (10.6%), eye shield (10.6%), pregnancy wheel used for GA determination (10.6%), and neonatal resuscitation bag (12.8%). Overall, supplies related to newborn care were in short supply.

Table 24: Availability of MNCH equipment and supplies at HP level, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Yes No Equipment and supplies N(%) N(%) MUAC tape 45 (95.7) 2 (4.3) Clinical thermometer 44 (93.6) 3 (6.4) Fetoscope 41 (87.2) 6 (12.8) Puncture proof sharp waste container 39 (83.0) 8 (17.0) Puncture proof sharps container 38 (80.9) 9 (19.1) Chlorhexdine solution (savlon) 38 (80.9) 9 (19.1) Syringe with needle 38 (80.9) 9 (19.1) Stethoscope 36 (76.6) 11 (23.4) Examination couch 35 (74.5) 12 (25.5) Cups for drinking water 35 (74.5) 12 (25.5) Functional baby scale 35 (74.5) 12 (25.5) Disposable latex examination glove 35 (74.5) 12 (25.5) Functional weighing scale adult 34 (72.3) 13 (27.7) Medical waste disposal box 33 (70.2) 14 (29.8) Cup for ORS 33 (70.2) 14 (29.8) Tray for ORT corner 32 (68.1) 15 (31.9) Functional BP apparatus 30 (63.8) 17 (36.2) 1 liter measuring container 29 (61.7) 18 (38.3) Spoon for ORS 29 (61.7) 18 (38.3) Regular trash bin 28 (59.6) 19 (40.4) Dust bin 24 (51.1) 23 (48.9) Cloth for ORT corner 24 (51.1) 23 (48.9) Functional timer 20 (42.6) 27 (57.4) Tape measure 19 (40.4) 28 (59.6) Clean water in a container 17 (36.2) 30 (63.8) Bucket for decontamination solution 15 (31.9) 32 (68.1) Prepared disinfection solution 9 (19.1) 38 (80.9) Bleach or bleaching powder (chlorine) 8 (17.0) 39 (83.0) Neonatal resuscitation bag 250 - 300ml 6 (12.8) 41 (87.2) Drape 6 (12.8) 41 (87.2) Pregnancy wheel (GA determination) 5 (10.6) 42 (89.4) Eye shield 5 (10.6) 42 (89.4) Face mask size 0 and 1 5 (10.6) 42 (89.4) Soap and towel or hand rub 5 (10.6) 42 (89.4) Penguin section bulb 3 (6.4) 44 (93.6) Washable Mackintosh 2 (4.3) 45 (95.7) Hand watch 0 (0.0) 47 100)

5.7.1.7.2 Availability of unexpired drugs on the day of visit

Zinc was the most available drug at the time of the survey which was present in 38 (80.9%) HPs, followed by Mebendazole/albendazole in 32 (68.1%) HPs, Amoxicillin 250mg dispersible tablet, Vit A and ORS in 31 (61.0%) HPs each. Least available drugs were ’ Plumpy nut, chloroquine, vitamin K. Certain drugs were reported to have never been received in several HPs. Coarterm was never received in 12 (25.5%) HPs, amoxicillin suspension in 18 (38.3%) HPs, and folic acid was never received in 21 (44.7%) HPs. Not taking in to consideration those drugs which were never received, high stock out lasting 7 or more days was reported for gentamycin 10 mg/ml ampule (68.4%). Duration of stock out – ranged from 7 90 days for different drugs. Gentamycin 10mg/ml enough to treat at least 5 children was available only in 1 of the 13 HPs that had the supply (Table 25).

Table 25: Availability of UNEXPIRED drugs, stock of status and average duration at HP level, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Stock out for 7 or Available (Total N=47) Duration of stock out more days Never Yes No Received Yes No Drug N( %) N(%) N(%) N(%) N(%) Min Max Mean Zinc 38 (80.9) 8 (17.0) 1 (2.1) 9 (19.6) 37 (80.4 7 90 63.1 Mebendazole/albendazole 32 (68.1) 12 (25.5) 3 (6.4) 12(27.3) 32 (72.7) 7 90 70.8 Amoxicillin 250mg dispersible tab 31 (66.0) 11 (23.4) 5 (10.6) 12 (28.6) 30 (71.4) 7 90 52.5 ORS 31 (66.0) 15 (31.9) 1 (2.1) 20(43.5) 26 (56.5) 7 90 48.4 Vitamin A 31 (66.0)) 12 (25.5) 4 (8.5) 15 (34.9) 28 (65.1) 10 90 61.4 Syringe with needle (1 or 2 cc; insulin syringe) 29 (61.7) 7 (14.9) 11 (23.4) 10 (27.8) 26 (72.2) 7 90 41.0 Paracetamol 27 (57.4) 15 (31.9) 5 (10.6) 15(35.7) 27 (64.3) 9 90 57.9 Coartem 24 (51.1) 11 (23.4) 12 (25.5) 16 (45.7) 19 (54.3) 15 90 65.6 surgical glove (6.5-8), box of 50 available 24 (51.1) 7 (14.9) 16 (34.0) 8 (25.8) 23 (74.2) 20 90 55 RDT 22 (46.8) 12 (25.5) 13 (27.7) 15 (44.1) 19 (55.9) 7 90 65.1 Tetracycline eye ointment 18 (38.3) 19 (40.4) 10 (21.3) 23 (62.2) 14 (37.8) 15 90 65.8 Cotrimoxazole 16 (34.0) 23 (48.9) 8 (17.0) 24(61.5) 15 (38.5) 7 90 65.9 Amoxicillin suspension (125mg/5ml) bottles 15 (31.9) 14 (29.8) 18 (38.3) 15 (51.7) 14 (48.3) 7 90 58.4 Folic acid 13 (27.7) 13 (27.7) 21 (44.7) 14 (53.8) 12 (46.2) 15 90 56.7 Gentamycin 10mg/ml ampoule (20mg/2ml) 13 (27.7) 25 (53.2) 9 (19.1) 26 (68.4) 12 (31.6) 15 90 58.1 Chloroquine 11 (23.4) 12 (25.5) 24 (51.1) 13 (56.5) 10 (43.3) 7 90 73.2 Plumpy Nut/RUTF 8 (17.0) 5 (10.6) 34 (72.3) 6 (46.2) 7 (53.8) 60 90 85.0 Vitamin K injection 2 (4.3) 8 (17.0) 37 (78.7) 8(80.0) 2 (20.0) 15 90 69.3

5.7.1.8 Job aids and guidelines Job aids and guidelines were in short supply at service delivery points. Newborn health related job aids were found rarely, though this was put as an important input in the guideline and as well as in training materials list (Table 26).

Table 26: Availability of job aids and guidelines at HP level, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=47) Yes No Job aids and guidelines n, % n, % – CBNC ICCM chart booklet 36 (76.6) 11 (23.4) Job aids on PNC 20 (42.6) 27 (57.4) CBNC wall chat 18 (38.3) 19 (61.7) Infection prevention wall chart 9 (19.1) 38 (80.9) back bag 6 (12.8) 41 (87.2)

5.7.1.9 Community Mobilization/demand creation

All the 47 HPs have community health promoters/HDAs in the kebele. There were a total of 6020 one-to-five networks and 1220 one-to-thirty networks in the community. Overall 39 (83.0%) HPs reported orienting or training HDAs in their respective kebeles in the last three months on MNCH issues. In the last 3 months, 38 (80.9%) HPs said they have conducted monthly meeting with HDAs, 41 (87.2%) HPs have received information on the number of pregnant women in the community, 16 (34%) HPs said they have received information on number of newborns with danger signs, 6 (12.8%) HPs said they have received information on the number of newborns with very severe disease from the HDAs. With respect to meeting with the HDAs, 36 (76.6%) HPs said they have met with HDAs as a group in the kebele in the last three months with a total of 151 meetings which is far low compared to the total number of HDA networks. On the presence of Command Post/Social Mobilization Committee, 44 (93.6%) HPs reported the presence of Command Post in their respective kebele and 86.4% said they have received report on pregnant women in the community from the Command Post and 44 (100%) said they have submitted reports to the Command Post regularly.

5.7.1.10 Supervision and support

Forty two (89.4%) HPs said they have received at least one supportive supervision in the last 3 months and oral feedback was the most common method of communicating supervision findings in 41 (97.6%) HPs. In 25 (59.5%) HPs the supervision was made by health center 73

staff, in 11 (26.2%) HPs it was done by woreda health staff, in 3 (7.1%) HPs by HEW supervisor, and in 2 (4.8%) HPs by NGO staff.

5.7.1.11 Recording and reporting formats More than 90% HPs had the relevant registers. However half to one-third HPs lack reporting formats (Table 27). Table 27: Availability of recording and reporting forms at HP level, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Yes No Recording and reporting formats N( %) N( %) ICCM register 45 (95.7) 2 (4.3) Family folder 44 (93.6) 3 (6.4) ANC register 43 (91.5) 4 (8.5) CBNC register 42 (89.4) 5 (10.6) Monthly reporting format 42 (89.4) 5 (10.6) Vaccination card 42 (89.4) 5 (10.6) Health post monthly service delivery report form 41 (87.2) 6 (12.8) Family Planning register 39 (83.0) 8 (17.0) Family Health card 39 (83.0) 8 (17.0) Health post annual service delivery report form 38 (80.9) 9 (19.1) Health post quarterly service delivery report form 35 (74.5) 12 (25.5) PNC register 35 (74.5) 12 (25.5) Pregnant woman and outcome registration book 35 (74.5) 12 (25.5) Health post disease information Tally 32 (68.1) 15 (31.9) Health post tracer drug availability Tally 32 (68.1) 15 (31.9) Request and re-supply form 30 (63.8) 17 (36.2) Health post service delivery Tally 30 (63.8) 17 (36.2) Supervision checklist 27 (57.4) 20 (42.6) Referral slip 21 (44.7) 26 (55.3) Stock card/bin card 21 (44.7) 26 (55.3) Birth Preparedness and Complication Readiness (BPCR) form 21 (44.7) 26 55.3)

5.7.2 Results of health center (HC) assessment

5.7.2.1 Distribution of surveyed health centers by zone and woreda

Forty eight (100%) health centers, (32 from the three zones of SNNPR [Bench Maji 12, Keffa 12, Segen 8] and 16 health centers from Jimma zone in Oromia Region) were assessed in this baseline survey (Table 28). Twenty eight (58.3%) were rural and 20 (41.7%) were urban health centers.

Table 28: Distribution of surveyed health centers by zone and woreda in SNNP and Oromia Regions; UNICEF/KOICA Baseline survey, March 2017

Regions Zones Woredas Number of HC assessed Meinit Goldia 4 Bench Maji Shebench 4 South Bench 4 Chena 4 SNNPR Keffa Gimbo 4 Tello 4 Amaro 4 Segen Konso 4 Dedo 4 Gomma 4 Oromia Jimma Mana 4 Sokrou 4 Total 48

5.7.2.2 Facility Structure and Referral Services

Seventeen (35.4%) HCs had piped connection in to the facilities, 8 (16.7%) HCs had piped connection in to the yard and 8 (16.7%) HCs access water from protected dug well, 4 (8.3%) HCs used surface water, 3 (6.3%) HCs used unprotected spring, and 2 HCs used rain water. Water supply was not available in all the facilities with piped water supply on the day of the visit. Thirty five (72.9%) HCs obtained power from electric grid and 6 of these had additional generator and another two had solar source for power supply (Table 29). In 42 (87.5%) HC hygienic toilets were accessible for users. Thirty three (68.8%) HCs had access to cell phone signal. Twenty seven (56.3%) HCs said they have motorized transport for use during referral and of these 22 (81.5%) HCs were motorbikes. Sixteen (72.7%) HCs had only one motorbike and 5 of these were not functional on the day of survey. Ten (20.8%) HCs have car/ambulances to be used for referral. Forty six (98.5%) HCs have access to ambulance services for referral of patients. Staff mobile phone was the most commonly used means of communication to facilitate referral and other activities (Table 29).

Table 29: Main source of drinking water and electric power supply for the HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Source of Electricity Number Percent (Total N=48) Electric Grid 27 56.2 Solar Panel 7 14.6 Generator 2 4.2 Electric grid + Generator 6 12.5 Electric grid + Solar 2 4.2 Other (Specify) 4 8.3 Facility of usual referral Primary Hospital 30 62.5 General Hospital 7 14.6 Specialized Hospital 6 12.5 Others 5 10.4 Means of communication Facility landline or mobile phone 12 25.0 Staff mobile phone 36 75.0

Structure and referral Hygienic toilets accessible for users 42 87.5 Cellphone signal 33 68.8 Motorized transport for referral 27 56.3 Access to ambulance 46 95.8

With respect to approximate distances between the HCs and the referral primary hospitals, 11 (22.9%) HCs were located within 10 Km distance, another 11 (22.9%) HCs were located – between 11 20 Kms and 19 (39.6%) HCs were located 31 Km or more to the referral – hospital. The range is between 1 128 Km with a mean of 38.9 kms.

5.7.2.3 ANC Services 5.7.2.3.1 Availability of ANC services and staffing

ANC services were available in all 48 (100%) HCs. Forty seven (97.9%) HCs provide ANC service 5 days a week. Twenty one (43.8%) HCs provide service including the weekends and more hours than the stated 8 hrs. Forty three (89.6%) HCs are open 8 hours a day, and 4 (8.3%) HCs are open 7 hours a day (Table 30). As observed in several sites, the health professionals live within the compound of the HCs which could reflect their readiness to give the service on any day of the week and at any time of the day.

Table 30: ANC service availability at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

ANC service days in a week Number (Total N=48) Percent 1 1 2.1 5 26 54.2 7 21 43.8

ANC service hours in a day 2 1 2.1 7 4 8.3 8 35 72.9 12 8 16.7

Number of HWs serving at ANC

unit at a time 1 13 27.1 2 14 29.2 3 9 18.8 4 5 10.4 5 5 10.4 6 2 4.2

Only 13 (27.1%) HCs had dedicated staff for ANC. Of the 111 health workers in the 48 HC surveyed, diploma midwives form the major work force present in 43 (38.7%) HCs followed by diploma clinical nurses present in 25 (22.5%) HCs, health officers in 17 (15.3%) HCs, BSc midwives in 13 (11.7%) HCs, and BSc clinical nurses in 10 (9.0%) HCs. None of the HCs had general practitioners. In 44 (91.7%) HCs there were one or more staff trained on BEmONC. Overall, 64 (57.6%) staff providing ANC service were trained on BEmONC. Five staff had reported receiving new or refresher training and all were serving in the ANC unit. In 41 (85.4%) HCs, the ANC unit were not part of the staff rotation. Thirty five (72.9%) HCs have diploma midwives trained on BEmONC and 8 (16.7%) HCs have BSc midwives trained on BEmONC) (Table 31).

Table 31: ANC staffing and BEmONC training status at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 Available (Total N=48) HCs with staff trained on BEmONC Yes No Yes No Health workers category N(%) N(%) N(%) N( %) Health Officer 17 (35.4) 31 (64.6) 7(14.6) 41 (85.4) Clinical Nurse (BSc) 10 (20.8) 38 (79.2) 2 (4.2) 46 (95.8) Clinical Nurse (Diploma) 25 (52.1) 23 (47.9) 4 (8.3) 44 (91.7) Midwives (BSc) 13 (27.1) 35 (72.9) 8 (16.7) 40 (83.3) Midwives (Diploma) 43 (89.6) 5 (10.4) 35 (72.9) 13 (27.1)

5.7.2.3.2 ANC Room setup

Thirty seven (77.1%) HCs have waiting area for ANC clients, 30 (62.5%) have designated ’ ANC rooms. Only 2 health centers ANC rooms had running water at the time of the survey. Hand washing basin was present in 11 (36.7%) and soap in 10 (33.3%) HCs with designated ANC rooms. Overall there was shortage of job aids and guidelines at the ANC unit (Table 32).

Table 32: HC ANC room setup, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=48) Yes No ANC room setup N(%) N(%) Waiting area for ANC Clients 37 (77.1) 11 (22.9) Designated room for ANC 30 (62.5) 18 (37.5) Well lit room 30 (62.5) 18 (37.5) Room ventilated 29 (96.7) 1 (3.3) Auditory privacy 24 (80.0) 6 (20.0) Alcohol based hand sanitizer 23 (76.7) 7 (23.3) Visual privacy 23 (76.7) 7 (23.3) Hand washing basin 11 (36.7) 19 (63.3) Soap for hand washing 10 (33.3) 20 (66.7) Running water on the day of the survey 2 (6.7) 28 (93.3) Availability of Job aids FANC wall chart 28 (58.3) 20 (41.7) National PMTCT guideline 26 (54.2) 22 (45.8) MgSO4 treatment algorithm 20 (41.7) 28 (58.3) Obstetric Protocol 19 (39.6) 29 (60.4) IP wall chart 9 (18.8) 39 81.3)

5.7.2.3.3 Availability of Equipment, drugs and supplies

Equipment such as examination couch, functional BP apparatus, fetoscope and stethoscope were available in most HCs. However pregnancy wheel was available in only 7 (14.6%) HCs and fetal doppler in 12 (25%) of the HCs. Close to half of the HCs lack iron or iron folate. For details please see Table 33.

Table 33: Availability of equipment, supplies and drugs at HC ANC, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=48)

Yes No N(%) N(%) Availability of equipment, drugs and supplies Fetoscope 48 (100) 0 (0.0) HIV rapid Test kit 48 (100) 0 (0.0) Examination couch 47 (97.9) 1(2.1) Stethoscope 47 (97.9) 1(2.1) Sterile Gloves 47 (97.9) 1 (2.1) Clean Gloves 45 (93.8) 3 (6.3) Puncture proof sharp container 45 (93.8) 3 (6.3) Functional BP apparatus 45 (93.8) 3 (6.3) Antiseptic 40 (83.3) 8 (16.7) Functional weighing scale adult 40 (83.3) 8 (16.7) Medical waste disposal box 39 (81.3) 9 (18.8) Height measurement scale 37 (77.1 ) 11 (22.9) Multivitamin 31 (64.6) 17 (35.4) Iron tablet 27 (56.3) 21 (43.8) Iron folate tablet 22 (45.8) 26 (54.2) Fetal Doppler 12 (25.0) 36 (75.0) Pregnancy wheel (GA determination) 7 (14.6) 41 (85.4)

5.7.2.3.4 Services given to pregnant women at HC

Twenty one (43.8%) HCs were measuring Hemoglobin/hematocrit, 33 (68.8%) HCs were determining blood group. HIV test was provided in almost all HCs and syphilis test was available in 22 (45.8%) HCs. No ultrasound service is given in all the HCs. Overall, the services at HCs were given free of charge. All facilities provide counselling on EBF, FP, ’ women s nutrition and advice mothers on BPCR. Except for 2 HCs, the rest of the facilities provide PMTCT services. ART service was available in 16 (33.3%) HCs (Table 34). 79

Table 34: Availability of ANC services at HC, ANC, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (N=48) Free of charge

Yes No Yes No Services to pregnant women N(%) N(%) N(%) N(%) Delivery services 47 (97.9) 1 (2.1) 46 (97.8) 1 (2.2) HIV test 46 (95.8) 2 (4.2) 45 (97.8) 1 (2.2) Immunization of Pregnant 44 (91.7) 4 (8.3) 40 (90.9) 4 (9.1) Diagnosis and treatment of STIs 40 (83.3) 8 (16.7) 39 (97.5) 1 (2.5) Deworming 38 (79.2) 10 (20.8) 35 (92.1) 3 (7.9) Blood typing 33 (68.8) 15 (31.2) 32 (97.0) 1 (3.0) urine protein test 30 (62.5) 18 (37.5) 29 (96.7) 1 (3.3) PMTCT Option B plus 30 (62.5) 18 (37.5) 30 (100) 0 (0.0) Syphilis/VDRL test 22 (45.8) 26 (54.2) 26 (100) 0 (0.0) Hemoglobin/Hematocrit measurement 21 (43.8) 27 (56.3) 21 (100) 0 (0.0) IPT 17 (35.4) 31 (64.6) 16 (94.1) 1 (5.9) ART service 16 (33.3) 32 (66.7) 16 (100) 0 (0.0) In-patient service 15 (31.1) 33 (68.8) 14 (93.3) 1 (6.7) Ultrasound examination 0 (0.0) 48 (100) 0 (0.0) 0 (0.0)

5.7.2.4 Recording and reporting

Recording and reporting formats were available in most facilities. Forty seven (97.9%) HCs regularly compile and send monthly reports regularly (Table 35). Table 35: Recording and reporting at HC ANC, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=48)

Yes No N(%) N(%) Recording and Reporting ANC attendance recorded on a register 48 (100) 0 (00) Monthly report compiled and reported regularly 47 (97.9) 1 (2.1) ANC register 47 (97.9) 1 (2.1) Monthly reporting format 45 (93.8) 3 (6.3) Referral slip 35 (72.9) 13 (27.1)

5.7.2.5 Skilled Birth Attendance 5.7.2.5.1 Service availability, staffing and training

Of the 48 surveyed HC, 47(97.9%) HCs were providing delivery services 24 hours a day and seven days a week. There were a total of 340 health workers serving in the delivery units in the 47 HCs. The composition of 340 professionals working in the delivery room is as follows: Diploma clinical nurses 133 (39.1%), Diploma midwives 97 (28.5%), health officers 71 (20.9%) followed by BSc Clinical nurses 20 (5.9%). Only 7 (14.6%) facilities reported that staffs in the delivery room are included in the staff rotation. Thirty nine (81.3%) delivery units had staff trained on BEmONC and of these 14 (35.9%) HCs received the training in or after March 2016 (Table 36).

Table 36: Staffing of delivery units and BEmONC training status at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

HCs with staff training on BEmONC (Total Number Available (Total N=47) N=39) & Yes No Total Yes No percent Health personnel type N(%) N(%) number N(%) N(%) trained Diploma Midwives 45 (93.8) 2 (4.2) 97 36 (92.3) 3 (7.7) 68 (70.1) Health Officers 38 (80.9) 9 (19.1) 71 10 (25.6) 29 (74.4) 11 (15.5) Diploma Clinical Nurses 33 (70.2) 14 (29.8) 133 7 (17.9) 32 (82.1) 13 (9.8) BSc Clinical Nurses 18 (38.3) 29 (61.7) 20 0 (0.0) 39 (100) 0 (0.0) BSc Midwives 13 (27.7) 34 (72.3) 14 6 (15.4) 33 (68.8) 7 (50.0) Emergency IESO 2 (4.3) 45 (95.7) 4 0 (0.0) 39 (100) 0 (0.0) MSc Clinical Midwives 1 (2.1) 46(97.9) 1 38 (97.4) 1 (2.6) 1(100)

5.7.2.5.2 Assessment of delivery service area

Twenty nine (61.7%) delivery units had dedicated room for first stage of labour, and 36 (76.6%) have dedicated room for delivery. Sixteen (34.0%) have maternity room to admit pregnant women with complications and 35 (74.4%) have dedicated post-delivery rooms. Only 13 (27.6%) delivery rooms had heating source to keep the room warm and 12 (25.5%) had running water on the day of assessment. Thirty four (72.3%) delivery units had one delivery room only and 8 (17.10%) had 2 rooms. For details please see Table 37 and 38 below.

Table 37: Observation of delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=47) Yes No Observation of delivery service area N(%) N(%) Delivery room ventilated (at least one open window) 46 (97.8) 1 (2.2) Delivery room(s) have sufficient light source to perform tasks 42 (89.4) 5 (10.6) during the day Functioning toilet for patient/ client use 41 (87.2) 15 (12.8) Delivery room provide visual privacy 40 (85.1) 5 (14.9) Delivery unit have a maternity Waiting home 37 (78.7) 10 (21.3) Functioning toilet for visitors/ companions and family use 37 (78.7) 10 (21.3) Separate/dedicated room for delivery 36 (76.6) 11 (23.4) Soap nearby for hand washing 36 (76.6) 11 (23.4) Separate/dedicated room for Labor and delivery together 35 (74.4) 12 (25.6) Separate/dedicated post-delivery (postnatal) room 35 (74.4) 12 (25.6) Hand washing basin in the room 34 (72.3) 13 (27.7) Alcohol based hand sanitizer 33 (70.2) 14 (29.8) Sufficient light source to perform tasks at night 30 (63.8) 17 (36.2) Separate/dedicated room for Labor (first stage) 29 (61.7) 18 (38.3) Time where water supply was interrupted for one or more days 27 (57.4) 20 (42.6) (Last 1 week) Separate/dedicated Newborn corner 26 (55.3) 21 (44.7) Time where water supply was interrupted for one or more 24 (51.1) 23 (48.9) weeks (Last 1 month) Electric line connected to the facility generator 19 (40.4) 28 (59.6) Separate/dedicated maternity room to admit pregnant women 16 (34.0) 31 (66.0) with complications Heating source to keep the delivery room warm when needed 13 (27.6) 34 (72.4) Running water in the room during the assessment 12 (25.5) 35 (74.5) Time where delivery service was interrupted due to water 6 (12.7) 41 (87.3) shortage (last 1 month) Interruption of delivery service due to power outage (last 4 (8.5) 43 (91.5) 1month)

One HC has interrupted delivery service for 15 days and another one for 8 days due to power outage, and three facilities have interrupted delivery service for 15, 30 and 90 days due to water shortage respectively. Four (8.3%) HCs have no maternity beds, 9 (19.5%) have two beds, 10 (21.3%) have 3 beds, and 4 facilities have 14 beds (Table 38). Table 38: Maternity beds, rooms and floor materials of delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Yes Number of maternity beds n,% 0 4 (8.5) 1 2 (4.3) 2 9 (19.5) 3 10 (21.3) 4 5 (10.6) 5 4 (8.5) 6 2 (4.3) 7 4 (8.5) 8 2 (4.3) 9 0 (0.0) 10 2 (4.3) 11 0 (0.0) 12 2 (4.3) 13 0 (0.0) 14 4 (8.5) Number of delivery rooms 0 5 (10.6) 1 34 (72.4) 2 2 (4.3) 3 1 (2.2) Main material of the floor Plastic tiles 7 (14.9) Ceramic tiles 7 (14.9) Cement 34 (72.4)

5.7.2.5.3 Availability of job aids and guidelines

Family planning guideline was available in 46 (97.8%) delivery units and infection prevention for HIV/AIDS guideline was available in 34 (72.3%) delivery units. But the availability of other guidelines was inadequate where PMTCT guideline was available in 27 (57.4%), AMTSL guideline in 26 (55.3%), MgSO4 administration job aid in 22 (46.8%), and IP guideline was available in 11 (23.4%) HCs (Table 39). 84

Table 39: Job aids and guidelines in the delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Job aid and guidelines in the delivery unit of HC Yes No N(%) N(%) FP guidelines 46 (97.8) 1 (2.2) IP for HIV/AIDS (Universal Precautions) guideline 34 (72.3) 13 (27.7) Integrated management of pregnancy, childbirth, postpartum 33 (70.2) 14 (29.8) and newborn care (focus on routine care) guideline Neonatal resuscitation algorithm 29 (61.7) 18 (38.3) PMTCT guideline 27 (57.4) 20 (42.6) Active Management of third Stage of labor (AMTSL) 26 (55.3) 21 (44.7) guideline Management protocol on selected obstetric topics 23 (48.9) 24 (51.1) MgSO4 administration job aid 22 (46.8) 25 (53.2) Infection prevention guideline 11 (23.4) 36 (76.6)

5.7.2.5.4 Equipment and supplies in the delivery units

Fetoscope, IV cannula, decontamination container, bleaching power, puncture proof sharp container were available in all the 47 (100%) delivery units. Some of the important equipment and supplies lacking were like stretchers which was available only in 25 (53.2%) delivery units, wheelchairs in 22 (46.8%), obstetric forceps in 18 (38.3%), oxygen cylinders in 9 (18.8%), Doppler in 9 (19.5%), pulse oximeter in 6 (12.7%), and IV fluids in 2 (4.3%) delivery units. None of the delivery units have ultrasound (Table 40).

In addition to the absolute lack of the items, the number of certain reusable procedure related equipment are limited. Very few facilities have 4 or more of these equipment making it very difficult to provide service for subsequent clients when there is such a need (Table 41).

Table 40: Equipment and supplies in the delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Yes No Availability of equipment and supplies N(%) N(%) Prepared disinfection solution 46 (97.8) 1 (2.2) 40%/50% Glucose 46 (97.8) 1 (2.2) Complete delivery set 46 (97.8) 1 (2.2) Partograph form 46 (97.8) 1 (2.2) Functional BP apparatus 45 (95.7) 2 (4.3) Stethoscope 44 (93.6) 3 (6.4) Functional baby scale 44 (93.6) 3 (6.4) Disposable latex examination glove 44 (93.6) 3 (6.4) Examination table 42 (89.4) 5 (10.6) Clinical thermometer 42 (89.4) 5 (10.6) Urinary catheter 39 (82.9) 8 (17.1) Complete episiotomy/perineal/ set 39 (82.9) 8 (17.1) Non-sterile protective clothing 37 (78.7) 10 (21.3) First stage bed 33 (70.2) 14 (29.8) Adult ventilator bag and mask 31 (66.0) 16 (34.0) Labor/delivery table with stirrups 34 (72.3) 13 (27.7) Eye shield 31 (64.6) 17 (35.4) Heavy duty glove 30 (63.8) 17 (36.2) Labor/delivery table without stirrups 28 (59.6) 19 (40.4) Stretcher with trolley 25 (53.2) 22 (46.8) Wheelchair 22 (46.8) 25 (53.2) Cervical exploration and repair set 21 (44.7) 26 (55.3) Obstetric Forceps 18 (38.3) 29 (61.7) Chlorhexdine solution 18 (38.3) 29 (61.7) Functional vacuum extractor with different size cups 16 (34.0) 31 (66.0) Elbow length glove 14 (29.8) 33 (70.2) Alcohol 11 (23.4) 36 (76.6) Filled oxygen cylinder with cylinder carrier and key to open 9 (19.5) 38 (80.5) valve Doppler 9 (19.5) 38 (80.5) Watch or clock with second that can be easily seen 8 (17.1) 39 (82.9) Pulse oximeter 6 (12.7) 41 (87.3) Obstetric wheel (for measuring gestational age) 4 (8.5) 43 (91.5) IV Crystalloid fluid (N/S, D/W, DNS, Ringer) 2 (4.3) 45 (95.7) Ultrasound 0 (0.0) 47 (100)

Table 41: Quantity of delivery related equipment in the delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Functional Functional Complete Cervical manual electric Out let Mid delivery Complete exploration vacuum vacuum forceps forceps set episiotomy and repair extractor extractor (N= 18). (N=18) (N=46) set (N= 39) set (N= 21) (N=16) (N= 16) Number N(%) N(%) N(%) N(%) N(%) N(%) N(%) 1 1 (11.1) 8 (44.4) 0 (0.0) 6 (15.4) 1 (4.8) 9 (56.3) 10 (62.4) 2 4 (22.2) 1 (5.6) 8 (17.4) 12 (30.8) 5 (23.8) 4 (25.0) 1 (25.0) 3 4 (22.2) 2 (11.1) 5 (10.9) 6 (15.4) 8 (38.1) 1 (6.3) 1 (6.3) 4 1 (5.6) 1 (5.6) 14 (30.4) 9 (23.1) 4 (19.0) 1 (6.3) 0 (0.0) 5 1 (5.6) 2 (11.1) 11 (23.9) 3 (7.7) 1 (4.8) 1 (6.3) 1 (6.3) 6 3 (16.7) 1 (5.6) 3 (6.5) 1 (2.6) 0 (0.0) 0 (0.0) 0 (0.0) 7 1 (5.6) 2 (11.1) 1 (2.2) 1 (2.6) 1 (4.8) 0 (0.0) 0 (0.0) 8 1 (5.6) 0 (0.0) 2 (4.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 9 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 10 0 (0.0) 0 (0.0) 2 (4.3) 1 (2.6) 1 (4.8) 0 (0.0) 0 (0.0) 15 1 (5.6) 1 (5.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

5.7.2.5.5 Readily availability of drugs

Forty four delivery units (93.6%) had oxytocin, 43 (91.5%) had BCG and Polio vaccines. Available in limited facilities were magnesium sulphate which was available in 20 (42.6%) HCs, Phenobarbital in 21 (44.7%), phenytoin in 10 (21.3%), and chlorhexidine gel in 4 (8.5%) HCs. For details see Table 42 below. Table 42: Readily availability of drugs related to delivery services at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=47) Yes No Readily availability of drugs when needed N(%) N(%) Oxytocin 44 (93.6) 3 (6.4) BCG vaccine 43 (91.5) 4 (8.5) Polio 0 43 (91.5) 4 (8.5) Diazepam injection 37 (78.7) 10 (21.3) Adrenaline injection 37 (78.7) 10 (21.3) Misoprostol 34 (72.3) 13 (27.7) Vit K injection 34 (72.3) 13 (27.7) Magnesium sulfate injection -50% 32 (68.0) 15 (32.0) Hydrocortisone readily 25 (53.2) 22 (46.8) Ergometrine 24 (51.1) 23 (48.9) Magnesium sulfate injection (other than 50%) 20 (42.6) 27 (57.4) Phenobarbital injection 21 (44.7) 26 (55.3) Calcium gluconate 13 (27.6) 34 (72.4) 87

Methylergometric 12 (25.5) 35 (74.5) Phenytoin (diphenylhydantoin) 10 (21.3) 37 (78.7) Atropine 10 (21.3) 37 (78.7) Chlorhexidine gel 4 (8.5) 43 (91.5)

5.7.2.5.6 Services provided to women in labor

Ambulance services, FP and HIV test services were available in 46 (97.8%), 45 (95.7%), 45 (95.7%) delivery units respectively. Thirty two (68.0%) of the delivery units provide blood typing services, 31 (66.0%) do urine protein test, 26 (55.3%) do VDRL test, 22 (46.8%) do hemoglobin measurement. Most of these services were provided free of charge in most facilities except for in patient care, VDRL test, and STI treatment (Table 43). Table 43: Availability of services and fees for women in labor at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Free of charge (Total N=47) Services provided for pregnant women in Yes No Yes No labour and fees N(%) N(%) N(%) N(%) Ambulance service 46 (97.8) 1 (2.2) 45 (97.8) 1 (2.2) Family planning 45 (95.7) 2 (4.3) 44 (97.8) 1 (2.2) HIV test 45 (95.7) 2 (4.3) 44 (97.8) 1 (2.2) Blood typing 32 (68.0) 15 (32.0) 31 (96.9 1 (3.1) Urine protein test 31 (66.0) 16 (34.0) 30 (96.8) 1 (3.2) Diagnosis and treatment of STIs 28 (59.6) 19 (40.4) 28 (100) 0 (0.0) VDRL test 26 (55.3) 21 (44.7) 26 (100) 0 (0.0) Hemoglobin measurement 22 (46.8) 25 (53.2) 21 (95.5) 1 (4.5) In-patient service 17 (36.2) 30 (63.8) 17 (100) 0 (0.0) Intermittent Presumptive Treatment for malaria 17 (36.2) 30 (63.8) 16 (94.1) 1 (5.9)

5.7.2.5.7 Signal functions

The practice of signal functions over the last 3 months from the date of survey was assessed for all delivery units. The most practiced signal functions were assisted vaginal delivery in 36 (76.6%) delivery units followed by administration of antibiotics and resuscitation of newborn using bag and mask in 34 (72.3%) and 32 (68.0%) delivery units respectively. The least practiced signal functions were use of parenteral magnesium sulfate for [pre-] eclampsia and use corticosteroids in 7 (14.9%) and 5 (10.6%) delivery units respectively (Figure 1).

Signal functions in the last 3 months

Corticosteroids in preterm labor 10.6

Parenteral magnesium sulfate for [pre-] eclampsia 14.9 Removal of retained products 51.1

Manual removal of placenta 63.8 Parenteral oxytocin for hemorrhage 63.8 Newborn resuscitation 68.0

Antibiotics for maternal infection 72.3 Assisted vaginal delivery 76.6

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0

Figure 1: Signal functions in the delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Six (14.6%) HC have not performed any of the signal functions. Only 1 (2.1) HC performed the eight signal functions. Eleven (22.9%) HCs performed five of the eight signal functions and 10 (20.8%) HCs did six signal functions over the 3 months period prior to date of assessment (Figure 2).

Percent of facilities by signal functions 8 signal functions (all) 2.2 7 signal functions 10.6 6 signal functions 21.3 5 signal functions 23.4 4 signal functions 12.7 3 signal functions 4.3 2 signal functions 10.6 1 signal function 2.2 None 12.7 0.0 5.0 10.0 15.0 20.0 25.0

Figure 2: Status of facility practice of signal functions in the delivery units KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017.

5.7.2.5.8 Policy Implementations

In 20 (42.6%) delivery units, postpartum women stay for 24 hours, in 19 (40.4%) delivery units women were allowed to stay for 6 hours after delivery. Six HCs allowed mothers to stay – for 10 12 hours. Two facilities limited the stay for 2 hours and 1 facility allowed 48 hrs. Only 14 (29.8%) HCs carry out audits or case review of maternal deaths on routine basis and 13 (27.6%) said they have implemented the Maternal Death Surveillance and Response (MDSR) initiative and 12 (25.5%) register maternal deaths by cause. Eighteen (38.3%) HCs have MDSR committee and 11 (23.4%) said they do not know its existence. With respect to 89

auditing newborn deaths and still births on a routine basis, 12 HCs said they do the audit for both, 3 HCs said they do for newborn deaths only, 10 (21.3%) HCs do not audit at all and 23 ’ ’ (48.9%) said they didn t have death and haven t done any. On near miss reviews, 11 (23.4%) ’ said they are doing it on routine basis, 22 (46.8%) HCs didn t do it and 15 (32.0%) said they never had a near miss case.

5.7.2.5.9 Recording and reporting

All delivery units had labor and delivery registration books and in 42 (89.4%) it was complete and up to date. Thirty four units had referral slips. Notification of births to the Vital Events Registry Agency was practiced by 23 (48.9%) delivery units and the form is available in 19 (40.4%) HCs.

5.7.2.5.10 NEWBORN CORNER

A designated space for newborn resuscitation was available in 25 (53.2%) delivery units. Newborn resuscitation unit was available in 20 (80%) delivery rooms with designated newborn corner. Of these, only 12 (60%) have radiant warmer and 14 (70%) had the resuscitation kit on the unit. Eleven (55%) of the units had drawers and only 10 (50%) had oxygen bottles. Power connection to plug the radiant warmer was available in the area in 16 (64.0%) of the 25 newborn corners.

Of the 47 delivery units, 35 (74.4%) said they have staff trained on essential newborn care and in 25 (71.4%) delivery units the staff were trained in or after March 2016. Twenty eight (80%) of the delivery rooms that have trained staff reported that they assign a trained staff 24 hours a day and 7 days a week to provide essential newborn care. Sixty six (66.6%) trained staff were Midwives and were available in 35 HCs. Only 20 (42.6%) delivery units fulfil the – three criteria for a functional newborn corner presence of trained staff, availability of resuscitation equipment and designated space.

5.7.2.5.11 Availability of equipment, supplies and drugs

Forty two (89.3%) delivery units have tetracycline eye ointment, 39 (82.9%) have gentamycin, and 30 (63.8%) have ampicillin injections. Vit K was available in 31 (65.9%) delivery units. However chlorhexidine ointment was available only in 5 (10.6%) facilities. NBC guideline was available in 27 (57.4%), flow chart/action plan in 26 (55.3%), and hand washing poster in 11 (23.4%) of the newborn service area. Forty three (91.5%) have registration book and reporting format (Table 44).

Table 44: Availability of equipment, supplies and drugs in the delivery units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=47) Yes No Equipment and supplies n,% n,% Syringe 47 (100) 0 (0.0) Neonatal resuscitation bag 250 - 300ml 47 (100) 0 (0.0) Sterile glove 46 (97.8) 1 (2.2) Functional Baby Weighing scale 43 (91.4) 4 (8.6) Sterile equipment for cutting and tying the cord 42 (89.3) 5 (10.7) Mucous extractor 20ml, sterilizable and visually 36 (76.6) 11 (23.4) cleanable Face mask size 0 and 1 35 (74.5) 12 (25.5) I/V Cannula 24 G, 26 G 35 (74.5) 12 (25.5) Functional Room thermometer 23 (48.9) 24 (51.1) Functional Infant thermometer (low reading) 19 (40.4) 28 (59.6) NG Tube CH07, L40cm, sterile, disposable 15 (31.9) 32 (68.1) Towel for drying and wrapping the baby (Two per 11 (23.4) 35 (76.6) each live birth) Functional Oxygen cylinder 9 (19.1) 38 (80.9) Feeding cup 9 (19.1) 38 (80.9) Functional Clock 9 (19.1) 38 (80.9) Availability of drugs on the day of visit Tetracycline eye ointment 42 (89.3) 5 (10.7) Gentamycin injection 39 (82.9) 8 (17.1) Vit K injection 31 (65.9) 16 (34.1) Ampicillin injection 30 (63.8) 17 (36.2) Chlorehexidine ointment 5 (10.6) 42 (89.4) Availability of job aids NBC guideline 27 (57.4) 20 (42.6) Flow chart/action plan 26 (55.3) 21 (44.7) Hand washing poster 11 (23.4) 36 (76.6) Availability of recording and reporting

books/formats Registration book 43 (91.4) 4 (8.6) Reporting format 43 (91.4) 4 (8.6)

5.7.2.5.12 Newborn referral

Forty (85.1%) have a referral system in place. Twenty six 26 (55.3%) HCs keep copies of referred neonates and 21 (44.6%) have the standard referral slip/format for sick newborn. Fifteen (31.9%) have guidelines or protocols on referral of sick newborn and in 11 (73.3%) it is part of another guideline.

5.7.2.6 Postnatal Care 5.7.2.6.1 Service availability and staffing

Postnatal service was available in 47 (100%) health centers that provided delivery services. Diploma midwives make the major work force which were available in 43 (91.5%) HCs followed by diploma clinical nurses and health officers who were available in 29 (61.7%) PNC units (Table 45).

Table 45: Types of professionals providing PNC services at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Number Staffs involved in (Total N=47) providing postnatal Yes No Total Mini Max Mean services N(%) N(%) Integrated Emergency Surgical 2 (4.3) 45 (95.7) 4 2 2 2.0 Officer (IESO) Health Officers 29 (61.7) 18 (38.3) 46 1 5 1.59 MSc clinical midwives 0 (0.0) 47 (100) 0 0 0 0 BSc midwives 9 (19.1) 38 (80.9) 10 1 2 1.1 Diploma midwives 43 (91.5) 4 (8.5) 90 1 4 2.0 BSc clinical nurses 19 (40.4) 28 (59.6) 21 1 2 1.1 Diploma clinical nurses 29 (61.7) 18 (38.3) 82 1 12 2

5.7.2.6.2 Assessment of service area

Twenty nine (61.7%) HCs have designated area for PNC and 28 (96.6%) of these rooms were well ventilated and 27 (93.1%) have sufficient light source to perform tasks during the day and night. However, hand washing basin was available in 13 (44.8%), and alcohol based hand sanitizer in 12 (41.4%) PNC rooms. Only one PNC room had running water at the time of the assessment (Table 46).

Table 46: Assessment of service areas at PNC units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Yes No Assessment of service area N(%) N(%) Designated postnatal follow up room 29 (61.7) 18 (38.3) Well ventilated room 28 (96.6) 1 (3.4) Sufficient light source to perform tasks during the 27 (93.1) 2 (6.9) day and night Visual privacy 25 (82.8) 5 (17.2) Soap nearby for hand washing 13 (44.8) 16 (55.2) Alcohol based hand sanitizer 12 (41.4) 17 (58.6) Hand washing basin 9 (31.0) 20 (69.0) 92

Running water in the room on day of assessment 1 (3.4) 28 (96.6)

5.7.2.6.3 Provision of services All facilities provide counselling services on PMTCT, FP, Nutrition and EBF. All but 2 PNC clinics provide HIV testing services.

5.7.2.6.4 Availability of equipment, supplies, and drugs

Most of the PNC units have the standard routine equipment and supplies such as stethoscope, IV cannula, BP apparatus and waste disposal equipment. The most striking finding was the lack of chlorhexidine gel at most of the PNC units which was available in only 4 (8.5%) PNCs (Table 47).

Table 47: Availability of equipment, supplies and drugs at PNC units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Yes No Availability of equipment and supplies n,% n,% Stethoscope 46 (97.8) 1 (2.2) IV cannula 46 (97.8) 1 (2.2) Functional BP apparatus 44 (93.6) 3 (6.4) Disposable latex examination glove 44 (93.5) 3 (6.4) Decontamination container 43 (91.4) 4 (8.6) IV crystalloid fluid 43 (91.4) 4 (8.6) Puncture proof sharps container 42 (89.3) 5 (10.7) Prepared disinfection solution 41 (87.2) 6 (12.8) Functional baby scale 41 (87.2) 6 (12.8) Clinical thermometer 41 (87.2) 6 (12.8) Bleach or bleaching powder (chlorine) 40 (85.1) 7 (14.9) Regular trash bin 40 (85.1) 7 (14.9) Examination table 38 (80.8) 9 (19.2) Alcohol 34 (72.3) 13 (27.7) Foley catheter 32 (68.0) 15 (32.0) Chlorhexdine solution 30 (63.8) 17 (36.2) Eye shield 29 (61.7) 18 (38.3)

Readily availability of drugs when needed 40%/50% glucose 45 (95.7) 2 (4.3) Child vaccines 44 (93.6) 3(6.4) Oxytocin 42 (89.3) 5 (10.7) Analgesics 35 (74.5) 12 (25.5) Iron and folate tablet 33 (70.2) 14 (29.8) Misoprostol 31 (65.9) 16 (34.1) Chlorhexidine gel for cord care 4 (8.6) 43 (91.4)

5.7.2.6.5 Availability of guidelines, job aids and reporting formats at PNC

Thirty one (65.9%) of the PNC units have integrated management of pregnancy, childbirth, postpartum and newborn care (focus on routine care) guidelines and 29 (60.4%) have FP guideline. PMTCT and IP guidelines are available in 18 (38.3%) and 16 (34.0%) of the units respectively showing lack of readily available reference materials. Around 90% of the facilities have recording and reporting formats but still there were facilities with no registers or reporting formats (Table 48).

Table 48: Availability of guidelines, job aids and formats at PNC units at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=47) Yes No Availability of job aid and guidelines N(%) N(%) Integrated management of pregnancy, childbirth, postpartum 31 (65.9) 16 (34.1) and newborn care (focus on routine care) guideline Family planning guideline 29 (61.7) 18 (38.3) Postnatal danger signs and symptoms wall chart 26 (55.3) 21 (44.7) Management protocol on selected obstetric topics 20 (42.5) 27 (57.5) PMTCT guideline 18 (38.3) 29 (61.7) Infection prevention guideline 16 (34.0) 31 (66.0) Recording and reporting. Monthly report compiled and reported regularly 45 (95.7) 2 (4.3) Postnatal register 44 (93.6) 3(6.4) Monthly reporting format 44 (93.6) 3(6.4) Register complete and up-to-date 41 (87.2) 6 (12.8) Referral slip 31 (65.9) 16 (34.1)

5.7.2.7 IMNCI 5.7.2.6.2 Availability of IMNCI Service, staffing and training

All surveyed HCs provided IMNCI services and 43 (89.6%) had designated room for treating under-five children. There were a total of 127 staff treating children and 80 (63.0%) were trained on IMNCI. Nineteen (39.6%) facilities had two staff, 11 (22.9%) facilities had 3 staff, and 5 (10.4%) facilities have 5 staff working in under-five clinics. Diploma clinical nurses were available in 39 (81.3%) clinics followed by health officers in 30 (62.5%) clinics and BSs clinical nurses in 21 (43.8%) under-five clinics.

5.7.2.6.3 Service time and staff rotation

Twenty (41.7%) HCs had staff serving in the under-five clinic 24 hours a day and 7 days a week. Staff rotation affected only 7 (14.6%) of the facilities. Forty (83.3%) HCs had staff trained on IMNCI and in 14 (29.2%) HCs staff received their training in or after March 2016. Of the 48 HCs, staffs from 10 (20.8%) HCs have received refresher training (Table 49).

Table 49: Availability of guidelines, job aids and formats at under five clinics at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Number Staff serving at U5 Yes No Total trained on clinics N(%) N(%) number Min Max Mean IMNCI General Practitioners 0 (0.0) 48 (100) 0 0 0 0 0 MSc clinical nurses 1 (2.1) 47 (97.9) 1 2 2 2 2 Health officers 30 (62.5) 18 (37.5) 48 1 5 1.6 25 BSc clinical nurses 21 (43.8) 27 (56.3) 23 1 2 1.1 11 Diploma clinical 39 (81.3) 9 (18.7) 70 1 4 1.79 29 nurses

5.7.2.6.4 Availability of equipment and supplies

Forty five (93.8%) under-five clinics have MUAC tapes and 42 (87.5%) have functional thermometer. Only close to two third of the facilities have sufficient setup for the management of dehydration. Forty two (87.5%) clinics lack functional timer to accurately count a minute. Forty six (95.8%) facilities had chart booklets and 45 (93.8%) have registers. Only 32 (66.7%) have OTP registration book and 31 (64.6%) have OTP card (Table 50). Table 50: Availability of equipment, supplies, guidelines, job aids and formats at under five clinics at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (N=48) Availability of equipment and supplies in Yes No the U5 clinic N(%) N(%) MUAC tape 45 (93.8) 3 (6.3) Functional thermometer 42 (87.5) 6 (12.5) Functional scale 37 (77.1) 11 (22.9) Cup for ORS 29 (60.4) 19 (39.6) Spoon for ORS 28 (58.3) 20 (41.7) Tray for ORT corner 28 (43.8) 20 (41.7) 1 liter measuring container 26 (54.2) 22 (45.8) Clean water in a container 21 (43.8) 27 (56.3) Cloth for ORT corner 21 (43.8) 27 (56.3) Functional timer (that can accurately count 7 (14.6) 41 (85.4) a minute) Hand watch 6 (12.5) 42 (87.5) Availability of job aids, registers and forms Chart booklet 46 (95.8) 2 (4.2) – Registration book 2 59 months 45 (93.8) 3 (6.3) – Registration book 0 2 months 45 (93.8) 3 (6.3) Reporting format 43 (89.6) 5 (10.4) OPD diagnosis & attendance tally 38 (79.2) 10 (20.8) OTP registration book 32 (66.7) 16 (33.3) 95

Outpatient Therapeutic Feeding Program 31 (64.6) 17 (35.4) (OTP) Card Multichart 20 (41.7) 58.3)

5.7.2.6.2 Availability of IMNCI drugs and stock out status.

Antihelmenthics, zinc, paracetamol and TTC eye ointment were available in 48 (100%), 46 (95.8%), 46 (95.8%) and 45 (93.8%) of the facilities respectively on the day of the assessment. Only half to one-third of the facilities had drugs like Vit K, Plumpy nut, ampicillin and anti-malarias on the day of the assessment. Certain facilities had never received F- 100 and F-75, 31 (64.6%) and 32 (66.7%) respectively. Among those facilities that had the drugs on the day of assessment, up to 10% of them had experienced stock outs lasting 7 or more days in the last 3 months (Table 51)

Table 51: Availability of IMNCI drugs on the day of assessment and stock out status at HCs, KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017 “ ” Stock out for 7 or more If Yes Duration of Available (Total N=48) days stock out Never Yes No Received Yes No Drug N(%) N(%) N(%) N(%) N(%) Min Max Mean Mebendazole/albendazole 48 (100) 0 (0.0) 0 (0.0) 3 (6.3) 45 (93.8) 20 90 46.7 Zinc 46 (95.8) 2 (4.2) 0 (0.0) 6 (12.5) 42 (87.5) 7 90 60.1 Paracetamol 46 (95.8) 2 (4.2) 0 (0.0) 4 (8.3) 44 (91.7) 7 90 39.5 Tetracycline eye ointment 45 (93.8) 2 (4.2) 1(2.1) 7 (14.9) 40 (85.1) 7 90 48.3 Cotrimoxazole 42 (87.5) 6 (12.5) 0 (0.0) 11 (22.9) 37 (77.1) 7 90 54.6 Gentamycin injection 42 (87.5) 4 (8.3) 2 (4.2) 9 (19.6) 37 (80.4) 7 90 36.9 RDT 40 (83.3) 4 (8.3) 4 (8.3) 4(9.1) 40 (90.9) 7 90 69.3 Ciprofloxacin tablet 39 (81.3) 8 (16.7) 1 (2.1) 10 (21.3) 37 (94.9) 7 90 49.2 Chloroquine 39 (81.3) 6 (12.5) 3 (6.3) 8 (17.8) 37 (82.5) 15 90 76.8 Amoxicillin suspension 37 (77.1) 11 (22.9) 0 (0.0) 15 (31.3) 33 (68.8) 7 90 40.3 ORS 37 (77.1) 11 (22.9 0 (0.0) 17 (35.4) 31 (64.6) 7 90 49.4 Vitamin A 36 (75.0) 9 (18.8) 3(6.3) 10 (22.2) 35 (77.8) 30 90 75.0 Vitamin K injection 33 (68.8) 11 (22.9) 4 (8.3) 14 (31.8) 30 (68.2) 30 90 73.2 Plumpy Nut/RUTF 31 (64.6) 13 (27.1 4 (8.3) 14 (31.8) 30 (68.2) 7 90 62.2 Crystalline Penicillin 30 (62.5) 9 (18.8) 9 (18.8) 10 (25.6) 29 (74.4) 20 90 59.0 Quinine Oral tablet 29 (60.4) 9 (18.8) 10 (20.8) 10 (26.3) 28 (73.7) 7 90 59.3 Ampicillin inject 28 (58.3) 15 (31.3) 5 (10.4) 16 (37.2) 27 (62.8) 15 90 53.8 Folic acid 27 (56.3) 12 (25.0) 9 (18.8) 14 (35.9) 25 (64.1) 7 90 48.6 CAF injection 26 (54.2) 10 (20.8) 12 (25.0) 13 (36.1) 23 (63.9) 30 90 54.0 Quinine Injection 26 (54.2) 11 (22.9) 11 (22.9) 11(29.7) 26 (70.3) 7 90 82.2 Coartem 19 (39.6) 26 (54.2) 3 (6.3) 5(11.1) 40 (88.9) 7 90 10.5 F-100 7 (14.6) 10 (20.8) 31 (64.6) 12 (70.6) 5 (29.4) 7 90 65.2 F-75 6 (12.5) 10 (20.8) 32 (66.7) 10 (62.5) 6 (37.5) 30 90 78.0

5.7.3 Results of hospital assessment

5.7.3.1 Distribution of hospitals

Eight hospitals (5 from SNNPR and 3 from Oromia) were assessed in this survey. Seven were primary and 1 was general hospital (Table 52). Data collection from the general hospital was limited to NICU services only. Table 52: Distribution of surveyed hospitals by region, Zone, and type: UNICEF/KOICA Baseline survey, March 2017

Region Zone Name of hospital Type of hospital SNNP Keffa Wacha Meles Zenawi Primary Gebire tsadik general hospital General Segen Karat Primary Gidole Primary Kele Primary Oromia Jimma Shenan Gibe Primary Seka cherkosa Primary Agaro Primary

5.7.3.2 Facility structure and referral services 5.7.3.2.1 Drinking water, electricity, sanitation and telephone access

All assessed hospitals were getting water from piped connection. In one hospital the piped connection was only to the facility yard. In five hospitals water supply was not available on the day of visit. All hospitals are connected to national electric grid and one hospital has additional generator. Hygienic toilets were accessible in all the hospitals except one (Gidole primary hospital). Cell phone signal was not detectable in 3 hospitals namely Karat, Gidole, and Kele primary hospitals. 5.7.3.2.2 Referral Service

All surveyed hospitals had car/ambulances, five had motorbikes and all were functional. Four facilities were using landline and the remaining four were using staff mobile phone for making communication. All primary hospitals refer to the general hospital. Gebre Tsadik general hospital refers patients to Jimma Specialized hospital.

5.7.3.3 MNCH services 5.7.3.3.1 Antenatal care service 5.7.3.3.1.1 Availability of ANC services ANC service was available 8 hours a day and 5 days a week in 6 of the 7 primary hospitals. Karat hospital has no ANC service. 5.7.3.3.1.2 Qualification, training and number of staffs at ANC

Of the 6 hospitals, 5 had at least 2 dedicated staff mainly BSc and diploma midwives working in the ANC unit. Diploma midwives were available in all the 6 primary hospitals that provide ANC service, and BSc midwives were available in four primary hospitals (Gidole, Shenan Gibe, Sheka Cherkosa), IESO only in Shenan Gibe hospital, and diploma clinical nurses were available only in Agaro hospital. All the health workers were trained on BEmONC and the training occurred before March 2016. No OBGY specialist was available in the primary hospitals, even for consultation. 5.7.3.3.1.3 Staff rotation and refresher trainings

In 5 hospitals staff rotation involves the health workers in ANC clinic. The rotation happens every 6 months in two and in less than 6 months in three primary hospitals. Refresher training on MNCH was given only for Wacha Meles Zenawi primary hospital before March 2016. A total of four health workers took the refresher training on ANC and at least one was still working in the hospital. 5.7.3.3.1.4 Service area, equipment, drugs, supplies and job aids

There were dedicated single ANC rooms in 5 hospitals and waiting area for ANC clients in 4 hospitals. All had good illumination and ventilation. Examination couch and functional BP apparatus, HIV test kit, Fetal Doppler and height measurement scale were available in all the 6 primary hospitals with ANC service. For details please see Table 70. In two hospitals obstetric protocol was not available at the ANC clinic where as national PMTCT guideline and FANC wall chart were available in only 3 hospitals. Iron tablets were available in 4 hospitals, deworming tablets in 5 hospitals, sterile gloves in 5 hospitals, and HIV test kit in all the 6 hospitals providing ANC services (Table 53).

Table 53: Equipment, drugs, supplies and job aids availability in primary hospitals; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=6) Service areas assessment Yes, (n) No, (n) Illumination(natural/electric) 6 0 Ventilation 6 0 Electric line with generator 6 0 Hand washing basin 6 0 Visual privacy 5 1 Soap 5 1 Alcohol based sanitizer 5 1 Auditory privacy 5 1 Running water on day of survey 2 4 Equipment, drugs, supplies and job aids Examination couch 6 0 Functional BP apparatus 6 0 HIV rapid test kit 6 0 Height measurement scale. 6 0 Fetal doppler 6 0 Stethoscope 5 1 Deworming tablets 5 1 Sterile gloves 5 1 Clean gloves 5 1 Puncture proof sharp waste container 5 1 Pregnancy wheel (GA determination) 5 1 Iron tablets 4 2 Folate tablets 4 2 Multivitamins tablets 4 2 Antiseptic solution 4 2 Obstetric protocol 4 2 Functional weighing scale adult 3 3 Medical waste disposal box 3 3 National PMTCT guideline 3 3 FANC wall chart 3 3 MgSO4 treatment algorithm for PE/E 2 4 Infection prevention wall chart 1 5

5.7.3.3.1.5 Services provided to pregnant women

Hemoglobin measurement, blood group typing, HIV testing, VDRL, URIN protein, delivery including C/S and in patient service was provided free of charge in all the 6 hospitals. Shenan Gibe hospital charges for ultrasound examination. Blood transfusion service was given in 4 hospitals. HBsAg test was done in 5 hospitals but was not free in 1 of them (Table 54).

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Table 54: Services provided at ANC in primary hospitals; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (N=6) Type of service Yes, (n) No, (n) Hemoglobin/ Hematocrit measurement 6 0 HIV testing 6 0 VDRL test 6 0 Urine protein 6 0 Ultrasound examination 6 0 In-patient service 6 0 Delivery service 6 0 Cesarean section 6 0 PMTCT Option B plus 6 0 ART provided to pregnant 6 0 TT immunization 6 0 Diagnosis and treatment of STIs 5 1 HBsAg test 5 1 Blood transfusion 4 2 Deworming 4 2 IPT provided 3 3

5.7.3.3.1.6 Counselling services

All hospitals give counseling services on PMTCT, Breast feeding, family planning and ’ women s nutrition. 5.7.3.3.1.7 Record keeping

ANC register, monthly reporting format, and ANC attendance was available in all 6 hospitals and referral slip was available in all except Shenan Gibe hospital. Data were regularly compiled and reported on monthly basis in all the 6 primary hospitals with ANC service.

5.7.3.3.2 Delivery service 5.7.3.3.2.1 Availability of delivery services and staffing

Delivery service was available in all 7 primary hospitals 24 hours a day and 7 days a week. Most of the deliveries were attended by BSc and diploma midwives. Health officers trained for 5 months were also attending deliveries in Karat primary hospital. C/S delivery service ’ was available in all the 7 hospitals and was done by IESO s in 6 hospitals and by surgeon at Kele hospital. There was staff rotation in delivery room of 5 hospitals and the rotation is done every 6 month in 2 hospitals and in less than 6 months in 3 hospitals (Table 55).

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Table 55: Distribution of delivery service providers at primary hospitals by level of health care professionals; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Provide delivery service (Total N=7)

Yes, (n) No, (n) Qualification of health workers Diploma midwives 7 0 General Practitioners (GPs) trained in ESO 2 5 GPs not trained in Emergency Surgery and Obstetrics 2 5 Integrated Emergency Surgical Officers (IESO) 2 5 health officers 2 5 BSc midwives 2 5 BSc clinical nurses 2 5 Diploma clinical nurses 1 6 General surgeons 1 6 MSc Clinical midwives 0 7 OBGY specialists 0 7

Six primary hospitals had staff trained on BEmONC. In one facility the training was given after March 2016 (Table 56). Refresher training was given before March 2016 for 5 staffs in 2 hospitals. Table 56: Trained staff on BEmONC; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Qualification of BEmONC trainees Number of trainees General Practitioners 3 IESO 4 BSc Midwives 10 Diploma midwives 28 BSc clinical nurses 2 Diploma clinical nurses 12 Total 69

Six hospitals have dedicated rooms for delivery and maternity rooms and all had dedicated rooms for post natal mothers. Six hospitals have post C/S rooms. Dedicated space for newborn care was available in the 5 hospitals. Maternity waiting homes were available in 4 hospitals namely Karat (2 rooms), Wacha Meles Zenawi (3 rooms), Gidole (2 rooms) and Kele (2 rooms)

5.7.3.3.2.2 Maternity beds

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The highest number of maternity beds available was in Agaro Primary Hospital with 21 and the lowest was in Wacha Meles Zenawi Primary Hospital with only 1 maternity bed (Table 57). Table 57: Distribution of maternity beds by hospital; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017.

Hospital name Number of maternity beds Agaro Primary Hospital 21 Seka Chekorsa 16 Karat 11 Gidole primary Hospital 10 Shanan Gibe 5 Kele 4 Wacha Meles Zenawi Primary Hospital 1 Total 68

5.7.3.3.2.3 Delivery service area

All delivery units were well lit, had good ventilation and provide visual privacy and have access to generator. Heating source was available in 2 delivery units, the floor was ceramic in 4 and cement in 3 and functional toilet were available for clients in 4 and for visitors in 3 hospitals. Hand washing basin was available in 6 hospitals and 4 had running water on the day of visit. There was water interruption in the last 1 month for one or more weeks in the 3 hospitals namely Wacha Meles Zenawi, Kele and Seka Chekorsa primary hospitals. All except Seka Cherkosa hospital had soap and alcohol based sanitizer. . 5.7.3.3.2.4 Treatment guidelines, equipment, supplies and drugs

PMTCT guideline, management protocol on selected topics of obstetrics was available in the delivery areas in 4 hospitals. All hospitals have MgSo4 administration and neonatal resuscitation job aids. AMTSL and FP guidelines were not available at Shenan Gibe and Seka Cherkosa primary hospitals (Table 58) Table 58: Availability of treatment guidelines at delivery unit; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=7 Job aid/ guidelines Yes, (n) No, (n) MgSO4 administration job aid 7 - neonatal resuscitation algorithm 7 - active Management of third Stage of labor (AMTSL) guideline 6 1 family planning guideline 6 1 management protocol on selected obstetric topics 4 3 infection prevention guideline 4 3 integrated management of pregnancy, childbirth, postpartum and 4 3 newborn care (focus on routine care) guideline 103

Is infection prevention for HIV/AIDS (Universal Precautions) 4 3 guideline PMTCT guideline 4 3

First stage bed was available in all the 7 hospitals but adult ventilation was not available in 2 hospitals namely Shenan Gibe and Seka Cherkosa. Complete delivery set and perineal set was available in all the 7 primary hospitals (Table 59).

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Table 59: Availability of equipment and supplies at delivery unit; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=7) Equipment and supplies Yes, (n) No, (n) Non-Sterile Protective Clothing 7 0 Decontamination Container 7 0 Bleach Or Bleaching Powder (Chlorine) 7 0 Prepared Disinfection Solution 7 0 Regular Trash Bin 7 0 Puncture Proof Sharps Container 7 0 Chlorhexdine Solution (Savlon) 7 0 Alcohol 7 0 First Stage Bed 7 0 Complete Episiotomy/Perineal/ Set 7 0 Complete Delivery Set 7 0 Partograph 7 0 Stethoscope 7 0 Fetoscope 7 0 Functional Baby Scale 7 0 Functional Vacuum Extractor With Different Size Cups 7 0 Complete Cesarean Section Set 7 0 IV Cannula 7 0 40%/50% Glucose 7 0 Clinical Thermometer 7 0 Urinary Catheters 7 0 Ultrasound 7 0 Heavy Duty Glove 6 1 Functional BP Apparatus 6 1 Disposable Latex Examination Gloves 6 1 Examination Table 6 1 Eye Shield 6 1 Cervical Exploration And Repair Set 6 1 Obstetric Forceps 6 1 Iv Crystalloid 6 1 Complete Laparotomy Set 5 2 Filled Oxygen Cylinder With Cylinder Carrier And Key To 5 2 Open Valve Adult Ventilator Bag And Mask 5 2 Labor/Delivery Table With Stirrups 5 2 Watch Or Clock With Second 5 2 Stretcher With Trolley 4 3 Labor/Delivery Table Without Stirrups 4 3 Pulse Oximeter 4 3 Elbow Length Gloves 4 3 Doppler 3 4 Obstetric Wheel 3 4

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Misoprostol, oxytocin, MgSo4 and calcium gluconate were readily available in all the 7 primary hospitals where as adrenalin, atropin, hydrocortisone, diazepam, and polio 0 were readily available in 6 of the primary hospitals (Table 60). Table 60: Readily availability of drugs when needed; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Readily available (Total N=7) Drug Yes, (n) No, (n) Calcium gluconate 7 0 BCG vaccine 7 0 Misoprostol 7 0 Oxytocin 7 0 Magnesium sulfate injection - 50% concentration 7 0 Atropine 6 1 Polio 0 6 1 Ergometrine 6 1 Adrenaline 6 1 Diazepam injection 6 1 Hydrocortisone 6 1 Vit K injection 5 2 Magnesium sulfate injection (other than 50%) 4 3 Methylergometric 4 3 Phenobarbital injection 3 4 Phenytoin (diphenylhydantoin) 2 5 Chlorhexidine gel 1 6

5.7.3.3.2.5 Services provided to pregnant women Services provided to pregnant women are shown in Table 61. Most basic services were available in all facilities, except for blood transfusion, laparotomy and IPT. Table 61: Distribution of services available in the surveyed hospitals; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=7) Service Yes, (n) No, (n) Hemoglobin/ Hematocrit Measurement 7 0 Blood Typing 7 0 HIV Testing 7 0 VDRL Test 7 0 Urine Protein 7 0 Ultrasound Examination 7 0 In-Patient Service 7 0 Diagnosis And Treatment Of STI 7 0 Ambulance 7 0 Family Planning 7 0 C/S 7 0 Laparotomy 5 2 106

Blood Transfusion 4 3 IPT Provided 3 4

5.7.3.3.2.6 Recording and reporting of delivery services

Labor and delivery register, monthly reporting format, referral slip were available from all the 7 hospitals and the register was complete and up-to-date. Four hospitals notify all births to the Vital Events Registration Agency and the vital events registration form was available in the delivery room in these four hospitals.

5.7.3.3.2.7 Signal functions and implementation of policy

In the last 3 months before the survey, in 6 facilities health professionals have done removal of retained products, have administered parenteral oxytocin for haemorrhage, and have given parenteral magnesium sulfate for [pre-] eclampsia (Table 62). In the primary hospitals, the maximum duration of stay for mothers was 48 hours whereas the shortest reported stay was 3 hours. Five hospitals have carried out maternal death audit and review. Karat and Seka Cherkosa hospitals have no maternal deaths since establishment. Similarly MDSR initiative implementation and committee establishment was carried out in 5 hospitals. Only 4 hospitals have done newborn death and still birth review and near miss case reviews. Table 62: Signal function status of the surveyed hospitals; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available Signal functions performed by health professionals in the last 3 months in the facility Yes, (n) No, (n) Performed cesarean delivery and emergency laparotomy for 7 0 obstetric/gynecologic cases Assisted vaginal delivery in the past 3 months 7 0 Provided Corticosteroids for anticipated preterm delivery 6 1 Administered parenteral oxytocin for hemorrhage 6 1 Administered parenteral magnesium sulfate for [pre-] 6 1 eclampsia Manual removal of placenta 6 1 Administered antibiotics for maternal infection in the past 3 months 6 1 Removed retained products 6 1 Resuscitated a new born with bag and mask of a non- 5 2 breathing infant Done blood transfusion 5 2

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5.7.3.3.2.8 Newborn corner 5.7.3.3.2.8.1 Availability of newborn corner and staffing

Newborn corner was available in all the 7 hospitals, so were trained staffs on essential newborn care. The training was given after March 2016 in 5 hospitals and before March 2016 in 2 hospitals. The trainees were 4 health officers, 4 diploma clinical nurses, and 37 midwives. Only one facility received refresher training which was done after March 2016. A total of 8 midwives received the training and at least one trained staff is available 24hrs a day. There is staff rotation from the unit in the 4 hospitals, every less than 6 months at 3 and every 6 months at 1 hospital. Trained staffs are exempted from rotation only at Gidole hospital.

5.7.3.3.2.8.2 Service area, equipment, supplies and drugs

Newborn resuscitation unit was available in all the 7 hospitals however towels for drying the baby were available in 1 hospital only. Sterile cord care material was not available at Gidole primary hospital (Table 63). All the seven hospitals have ampicillin injection, gentamycin injection, and TTC eye ointment. Vitamin K injection was available in 6 (87.5%) hospitals but chlorehexidine ointment was available in only two hospitals.

’ Table 63: Available equipment s and supplies for the newborn corner; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available, N=7 Equipment and supplies Yes, (n) No, (n) Newborn Care Resuscitation Unit 7 0 Resuscitation Kit Placed On The Radiant Warmer 7 0 Syringes 7 0 Sterile Gloves 7 0 Baby Weighing Scale 7 0 I/V Cannula 24 G, 26 G 7 0 Mucous Extractor 20ml, Sterilizable And Visually Cleanable 7 0 (4) Radiant Warmer 6 1 Functional Neonatal Resuscitation Bag 250 - 300ml (2 6 1 Sterile Equipment For Cutting And Tying The Cord 6 1 Functional Oxygen Cylinder 8 F 6 1 NG Tube CH07, L40cm, Sterile, Disposable 5 2 Functional Clock 5 2 Functional Room Thermometer 5 2 Functional Infant Thermometer (Low Reading) 3 4 Face Mask Size 0 And 1 3 4 02 Bottles 3 4 Towels For Drying And Wrapping The Baby (Two Per Each 1 6 Live Birth) 108

Fixed Height Trolley With Drawers 1 6 Feeding Cups 1 6

5.7.3.3.2.9 Recording, reporting and referral

There was referral system in place in all the 7 hospitals and referral guideline was available in only 4 hospitals as part of another guideline. Standard referral slip format for sick new born was available in 6 hospitals. Copies for the referred neonates were seen at the 6 hospitals. 5.7.3.3.2.10 Availability of job aids

Registration book and reporting formats were available in all the 7 hospitals. NBC guideline and flow chart/action plan was available in 6 hospitals while hand washing poster was available in 5 hospitals.

5.7.3.3.3 Post natal care (PNC) 5.7.3.3.3.1 Availability of PNC services and staffing

PNC service was available in all the 7 hospitals 7 days a week. Service was mainly provided by diploma midwives, IESOs and health officers (Table 64).

Table 64: Availability of different professionals who provide PNC service; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=7) Number Of HWs Yes, (n) No, (n) Qualification available Diploma midwives 6 1 45 Health officers 3 4 7 BSc mid wives 2 5 19 IESO 2 5 15 BSc clinical nurses 1 6 2 Diploma clinical nurses 1 6 12

5.7.3.3.3.2 Observation of service area

There is a designated PNC room in all the 7 hospitals and hand washing basin was available ’ in 4 out of the 7 hospitals PNC rooms. There was no running water in all the hand washing basins at the time of survey where the maximum duration of water interruption was 90 days

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in 2 hospitals namely Shenan Gibe and Seka Cherkosa followed by 30 days at Wacha Meles Zenawi hospital.

5.7.3.3.3.3 Job aid and guidelines

PMTCT guideline, management protocol on selected obstetric topics and guideline on integrated management of pregnancy, childbirth, postpartum and newborn care was available in 5 of the primary hospitals. Post natal danger sign wall chart was not available in 1 hospital.

5.7.3.3.3.4 Equipment, supplies and readily availability of drugs

Most of the surveyed items and supplies were available in the hospitals except examination table which was available only in 3 hospitals (Table 65). Table 65: Availability of equipment and supplies; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=7) Equipment / supply Yes, (n) No, (n) Puncture Proof Sharps Container 7 0 Clinical Thermometer 7 0 Stethoscope Available 7 0 Bleach Or Bleaching Powder (Chlorine) 7 0 Disposable Latex Examination Gloves 6 1 Regular Trash Bin 6 1 Eye Shield 6 1 Alcohol 6 1 Functional BP Apparatus 6 1 Functional Baby Scale 5 2 Decontamination Container 5 2 Prepared Disinfection Solution 5 2 Chlorhexdine Solution (Savlon) 5 2 Examination Table 3 4

Chlorohexdin gel was the least readily available drug being available only at Wacha Meles Zenawi hospital. Child vaccines are not available at Karat hospital. Analgesic, IV crystalloid, IV cannula, foley catheter, 40%/50% glucose were available in all the 7 hospitals while iron tablets were available only in 5 hospitals (Table 66).

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Table 66: Readily availability of drugs when needed in primary hospitals; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=7) No, Yes, (n) Drugs (n) Analgesics 7 0 IV Crystalloid 7 0 IV Cannula 7 0 Foley Catheter 7 0 40%/50% Glucose 7 0 Oxytocin 7 0 Misoprostol 6 1 Child Vaccines 6 1 Iron And Folate Tablets 5 2 Chlorhexidine Gel For Cord Care 1 6

5.7.3.3.3.5 Counselling, recording and reporting

All the counselling services namely PMTCT, breast feeding, family planning, post natal ’ counselling and women s nutrition were available in all the 7 hospitals. Regarding recording and reporting, there was up-to-date PNC register and all reports are regularly complied and reported in all the 7 hospitals.

5.7.3.3.4 Neonatal intensive care unit (NICU) 5.7.3.3.4.1 NICU services accessibility and quality

A designated functional NICU was available in all the 7 primary hospitals and 1 general hospital. The unit is located in close proximity to the delivery rooms in the 6 hospitals. Referred infants are accepted to the NICU in all the 8 hospitals and transportation of newborns requires using public corridors in all hospitals with the exception of Gibe hospital. The main material of the floor was cement in the 3 hospitals and ceramic tile in the remaining 5 hospitals. The largest number of rooms in NICU was 4 in Gebre Tsadik hospital followed by 3 in Gidole, Sheka Cherkosa and Agaro hospitals . There was a step down area (an area where recovering neonates can stay with their mothers before discharge) in 3 hospitals. Regarding KMC rooms it was available and functional in 5 hospitals. In the 6 hospitals the unit allows constant surveillance of the neonates except at Karat and Shenan Gibe hospitals. There was a gowning area at the entrance in 4 hospitals (Table 67).

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Table 67: NICU service area observation; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available, N=8 No, Yes, (n) Quality parameter (n) Clean area for mixing intravenous fluids and medications 7 1 ’ Unit design allows constant surveillance of each bed from the nurses 6 2 station Unit has two interconnected rooms (baby care areas) separated by 6 2 transparent windows with the nurses work place in between Kangaroo Mother Care (KMC) 6 2 Hand washing station 6 2 Examination area 6 2 Gowning area at the entrance 4 4 Mothers area for breast milk expression 3 5 Step down area 3 5 Side laboratory 2 6 Boiling and autoclaving 2 6

5.7.3.3.4.2 Staffing of the NICU

The staffs assigned to work at NICU were 1 GP (G/Tsadik General hospital), 3 health officers, 9 BSc clinical nurses, 5 diploma midwives, and 1 porter (Gidole primary hospital). Only 4 hospitals have dedicated cleaners while none had medical bioengineer, neonatologist or paediatrician. Regarding NICU initial training, 4 hospitals have trained BSc nurses while another 3 have trained diploma nurses. Those who received the training were 8 in number and 5 received the training after March 2016. Diploma clinical nurses who received the initial NICU training from all the surveyed hospitals were 17 and 5 of them were trained after March 2016. Regarding observership at level III NICU, 8 BSc clinical nurses and 6 diploma nurses had the chance and all were received after March 2016. In all the hospitals, at least 1 trained staff was available at NICU for 24 hrs a day. There was staff rotation in the NICU in 4 hospitals and its frequency was less than every 6 months at 2 hospitals, every 6 month at one and unpredictable at Wacha Meles Zenawi Hospital. 5.7.3.3.4.3 Procedures, equipment and consumables and diagnostic services

IV canalization, insertion of NG tube, Oxygen administration, dressing was practiced in all 8 hospitals surveyed. Plasma transfusion, partial exchange, double exchange and surgical correction for any congenital abnormalities was not performed in all 8 hospitals. Hyaline membrane disease treatment with CPAP was available in Gebre Tsadik General Hospital only (Table 68).

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Radiant warmer set and resuscitation kit placed on the radiant warmer was available in all hospitals. Oxygen cylinder was not available in the NICU of one hospital (Table 69).

Table 68: Procedures done in NICU; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Procedure done (Total N=8) Procedure/treatments Yes, (n) No, (n) IV- Canalization 8 0 Dressing 8 0 Treatment Of Sepsis 8 0 Insertion Of NG Tube 8 0 Oxygen Administration 8 0 Management Of Asphyxiated Babies 7 1 Umbilical Catheterization 7 1 Hypothermia Correction And Treatment 7 1 Urine Catheterization 4 4 Central Vein Insertion Done 4 4 Stitching 4 4 Gastric Lavage 3 5 Blood Transfusion 3 5 Management Of Hyperbilirubinemia With 3 5 Phototherapy Intubation & Ventilation 2 6 Lumbar Puncture 1 7 Hyaline Membrane Disease Treatment With 1 7 CPAP Plasma Transfusion 0 8 Partial Exchange 0 8 Double Exchange 0 8 Surgical Correction For Any Congenital 0 8 Abnormalities

Table 69: Equipment and supplies at the NICU; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=8) Number available Yes, (n) No, (n) Equipment/consumables Radiant Warmer Set 8 0 16 Radiant Warmer Set Assembled 8 0 Resuscitation Kit Placed On The Radiant Warmer 8 0 Oxygen Cylinder Available 7 1 19 Oxygen Cylinder In Use 7 1 Phototherapy Set 6 2 14 Phototherapy Set Assembled And In Use 5 1 Incubator Set Available 7 1 26 113

At Least One Incubator Set Assembled And In Use 5 2 CPAP Set Available 1 7 1 At Least One CPAP Set Assembled And In Use 1 7 Neonatal Bed, Hospital Standard, With Mattress Available 7 1 34 Functional Oxygen Concentrator Available 7 1 22 ” Functional Thermometer, Clinical, Digital,32-43 C 7 1 13 Available Laryngoscope Set, Neonate Available 7 1 1 Functional Neonatal Resuscitation Bag Hand Operated 250 6 2 27 - 300ml Available Stand, Infusion, Double Hook, On Castors Available 6 2 17 Functional Stethoscope, Binaural, Neonate Available 6 2 8 Basin, Kidney, Stainless Steel, 825ml Available 6 2 13 Surgical Instrument Suture/SET Available 5 3 14 Functional Scale, Baby, Electronic, 10 Kg <5g> Available 5 3 6 Syringe Pump 10, 20, 50 Ml, Single Phase Available 4 4 27 Suture Set Available 4 4 13 Functional Wall Thermometer Available 4 4 4 Functional Glucometer 3 5 4 Tracheal Tube Available 3 5 7 Pump, Suction, Portable, 220V, With Accessories Available 3 5 5 Functional Pump, Suction, Foot- Operated Available 2 6 2 Oxygen Hood, Small And Medium, Set Of 3 Each, 3 5 9 Including Connecting Tubes Available Functional Pulse Oxymeter, Bedside, Neonatal Available 2 6 2 Functional Light, Examination, Mobile,220-12V Available 3 5 4 Tape Measure, Vinyl-Coated, 1.5m Available 3 5 4 Tray,Dressing,Ss,300x200x30mm Available 3 5 8 Oxygen Flow Splitter Available 3 5 9 Functional Refrigerator In The NICU Available? 3 5 3 LP Sets Available 1 7 3 Functional Computer Available 1 7 2 Functional TV Available 1 7 1 ‰ Infantometer, Plexi, 3 Ft/105cm (Length Measuring 1 7 1 Equipment) Available Functional Sphygmomanometer, Neonate, Electronic 1 7 2 Available Exchange Transfusion Set Three Way Valve Available 0 8 Functional Hub Cutter, Syringe (Devices That Remove 0 8 Needles From The Syringes) Available Functional Physiologic Vital Sign Monitoring Systems, 0 8 Neonatal Available

Blood sugar test, urine analysis and blood film were among the tests done in all the 8 hospitals, whereas SGOT/AST, SGPT/ALT testing, culture and sensitivity, coagulation profile and CSF analysis was done in only 2 hospitals (Table 70)

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Table 70: Availability of diagnostic services in NICU; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=8) Diagnostic services Yes, (n) No, (n) Blood Sugar Test 8 0 Blood Film 8 0 Urine Analysis 8 0 VDRL 7 1 Blood Group & RH Testing 7 1 Gram Stain 7 1 Hgb/HCT 6 2 Platelet Count 6 2 Hbsag Test 6 2 Wbc & Differential 5 3 Reticulocyte Count 5 3 Blood Morphology Testing 5 3 Albumin Testing 4 4 Total Protein Testing 4 4 BUN Testing Done 4 4 Creatinine Testing 4 4 Bilirubin Direct Testing 3 5 Bilirubin Total Testing 3 5 Bleeding Time 2 6 Coagulation Time 2 6 SGOT/AST, SGPT/ALT Testing 2 6 CSF- Cell Count 2 6 Hemoglobinometer / Centrifuge For The 2 6 Newborn CSF Glucose 2 6 Csf Protein 2 6 Culture And Sensitivity 2 6

5.7.3.3.4.4 Diagnostic equipment, job aids and recording formats

Functional X-ray service for the newborn and hemoglobinometer were available in two hospitals. Electrocardiogram for the newborn, electroencephalograph for newborns, color doppler ultrasound, echocardiograph for the newborn, blood gas/PH analyser service for the newborn, ultrasound for the newborn were not available in any of the hospitals. Neonatal resuscitation guide line was available in 7 hospitals, infection prevention in 6 and hand washing poster in only 4 hospitals. Reporting format was available in 7 but electronic data register was available in only 2 hospitals (Table 71).

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Table 71: Availability of guidelines, job aids, and formats at NICU; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=8) Guide lines/ job aids/ formats Yes, (n) No, (n) Guideline of the care for preterm babies or LBW babies, 5 3 including Kangaroo mother care Neonatal resuscitation guideline 7 1 Infection prevention guideline 6 2 Hand washing poster 4 4 Registration book 6 2 Reporting format 7 1 KMC register 4 4 electronic data recording 2 6

5.7.3.3.5 Availability of drugs

Ampicillin injection, gentamycin injection, ceftriaxone, cloxacillin sodium, metronidazone infection, and diazepam infection were available in all the eight hospitals. On the other hand, the least available drugs were chlorhexidine and nystatine in 2 hospitals and vitamin K injection in 3 hospitals (Table 72) Table 72: Availability of drugs; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=8) Drug Yes, (n) No, (n) Diazepam injection 8 0 Adrenaline 8 0 Ampicilline injection 8 0 Ceftriaxone 8 0 Gentamycin injection 8 0 Cloxacillin sodium 8 0 Metronidazole injection 8 0 Tetracycline eye ointment 7 1 BCG Vaccine 7 1 Phenobarbital injection 6 2 Cefotaxime injection for newborn 6 2 Polio 0 6 2 Calcium gluconate injection 6 2 Oral flucloxacillin 5 3 Amoxicillin injection 4 4 Vit K injection 3 5 Chlorehexidine 2 6 Clindamycin injection 2 6 Nystatin Oral 2 6 116

5.7.3.3.6 Referral service

Four hospitals responded having referral guidelines to refer sick newborns and all 4 mentioned it is part of another guide line. All surveyed hospitals refer newborns to nearby hospitals if they are not spontaneously breathing. For suspected severe neonatal infection 7 hospitals refer neonates to nearby referral hospital the same is true for premature neonates.

5.7.3.3.7 INTEGRATED MANAGEMENT OF NEWBORN AND CHILD ILLNESSES (IMNCI) 5.7.3.3.7.1 Availability of personnel treating under -five children.

All the primary hospitals treat children under the age of five years. Six hospitals have designated rooms to treat under-five children. The number of medical staff treating under- five children totals to 16. Out of which there were 4 GPs, 4 health officers, 4 BSc clinical nurses and 5 diploma clinical nurses. Five hospitals have received IMNICI training where the training in all was given before March 2016. Regarding the refresher IMNCI trainings, 3 hospitals reported having staffs that received the refresher training and the time was 1 hospital before March and the other 2 were after March 2016. There was staff rotation in the unit where in 2 hospitals it is done in less than 6 month, every 6 months in one hospital, and unpredictable in one other hospital.

– 5.7.3.3.7.2 Equipment in the under five clinics

Functional thermometer, functional weighing scale and MUAC tape were available in all hospitals Functional timer was not available in 6 hospitals (Table 73). Table 73: Availability of equipment in the under-five clinic; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Available (Total N=7) No, Yes, (n) Equipment (n) Functional Thermometer 7 0 MUAC tape 7 0 Cup For ORS 5 2 Spoon For ORS 5 2 Tray for ORT corner 5 2 Clean Water In A Container 4 3 Cloth for ORT corner 4 3 Hand-Watch 3 4 1 Liter Measuring Container 2 5 117

Functional Timer 1 6

5.7.3.3.7.3 Job aids and guidelines

OPD diagnosis & attendance tally and reporting formats were available in all the 7 hospitals. Registration book for 0 to 59 months children and OTP card were available in 6 hospitals while chart booklet and multichart were available in only 5 of the hospitals.

5.7.3.3.7.4 Availability of unexpired drugs on the day of visit

Unexpired cotrimoxazole, ORS, paracetamol, folic acid, gentamycin injection, CAF injection, crystalline penicillin, and ciprofloxacin were found in all the seven hospitals. Whereas, zinc, vitamin A, chloroquine, amoxicillin suspension, plumpy nut/RUFF, mebendazole/albendazole, tetracycline eye ointment, vitamin K injection, F-75, F-100, ampicillin injection, quinine, quinine oral tablet, and RDT were absent in at least one hospital. F-100 was never received in one hospital. There were no stock outs cotrimoxazole, zinc, coartem, chloroquine, paracetamol, folic acid, crystalline penicillin, and ciprofloxacin lasting for seven or more days. One to two hospitals have stock outs of different drugs lasting for seven or more days (Table 74).

Table 74: Availability of UNEXPIRED drugs, stock of status and average duration; KOICA/UNICEF Baseline survey, Oromia and SNNP, March 2017

Stock out for 7 or Available, N=7 Duration of stock out more days, N=7 Never Mean/act Yes, No, Received Yes, (n) No, (n) ual (n) (n) Drug (n) duration Min Max Cotrimoxazole 7 0 0 0 7 - - - ORS 7 0 0 1 6 14 - - Ciprofloxacin 7 0 0 0 7 - - - Crystalline penicillin 7 0 0 0 7 - - - Coartem 7 0 0 0 7 - - - Paracetamol 7 0 0 0 7 - - - Folic acid 7 0 0 0 7 - - - Gentamycin injection 7 0 0 1 6 7 - - CAF injection 7 0 0 1 6 30 - - Ampicilline injection 6 1 0 1 6 7 - - Quinine 6 1 0 1 6 90 - - Quinine oral tablets 6 1 0 1 6 90 - - RDT 6 1 0 1 6 90 - - Chloroquine 6 1 0 0 7 - - - Amoxicillin suspension 6 1 0 1 6 15 - - Plumpy Nut/RUTF 6 1 0 2 5 18 15 21 118

Mebendazole/albendaz 6 1 0 1 6 90 - - ole Tetracycline eye 6 1 0 1 6 90 - - ointment Zinc 5 2 0 0 7 - - - Vitamin A 5 2 0 1 6 90 - - Vitamin K injection 5 2 0 2 5 60 30 90 F-75 5 2 0 1 6 90 - - F-100 5 1 1 1 5 90 - -

5.7.4 Conclusions and recommendation on availability and quality of high impact MNCH services, MNCH equipment, drugs and supplies Conclusion Availability of key selected high impact MNCH Services Both ANC and PNC services are available in more than 90% of the HPs surveyed. The majority of the HPs are open 5 days a week and 8 hours a day to give the services Treatment for common childhood illnesses (ICCM) and CBNC are the two services provided at health post level. It is very encouraging to see that these two services are provided in more than 90% of the HPs. In most facilities child health service is available 5 days a week and 8 hours a day. Almost all health posts that provide CBNC services said they are available throughout the week to give care for sick newborns. ANC services are available in all surveyed health centers and are provided at least 5 days a week in more than 90% of the facilities. Except one, all HCs are providing delivery services 24 hours a day and seven days a week. Four fifth of the surveyed HCs have staff trained on BEmONC and most of them are practicing the signal functions. All facilities providing delivery service have PNC clinic which is encouraging. Only half of the delivery units have designated space for immediate newborn care and resuscitation but newborn resuscitation unit is available in less than half of the delivery units. – Only 20 (42.6%) delivery units fulfil the three parameters for a functional newborn corner presence of trained staff, availability of resuscitation unit and designated space. IMNCI service is also provided in all surveyed health centers 24 hours a day and 7 days a week with close to 90% having designated space for under 5 children. ANC services waere available in 6 surveyed primary hospitals and was accessible 8 hours a day and 5 days a week. Delivery services and postnatal care are provided in all the 7 surveyed primary hospitals 24 hours a day and 7 days a week. Midwives are the major workforce in the provision of maternal health services and most are diploma level graduates. The primary hospitals have most of the services required for maternal health services including cesarean section, though one third of them lack blood transfusion services.

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Newborn corner, NICU and IMNCI services are available in all 7 primary hospitals. BSc nurses and diploma midwives are the major workforce in all the units. Availability of key essential MNCH equipment, drugs and supplies Fetoscope and stethoscope are available in most but not all HPs. Only three-fourth or less surveyed HPs have examination couch, adult functional weighing scale, BP apparatus, and disposable latex examination glove. Less than half of the HPs have clean water and decontamination solution at the time of the survey. Very few HPs have Pregnancy Wheel to accurately estimate gestational age. Supplies like bleach, soap, towel, eye shield and drape are scarcely available. MUAC tape and clinical thermometer are widely available though not in all HPs. A quarter of the HPs lack functional baby scale compromising identifying children with growth faltering. One third to half of the facilities lack a proper ORT setup, lacking spoons, trays and cloth and three quarters of the facilities lack clean water. This is serious gap as dehydration is one of the important causes of child death and the setup should have been much better. Very few facilities have neonatal resuscitation bag, face mask and section bulb. Although the HPs are not expected to provide delivery services, the HEWs could encounter newborns that need their immediate assistance and therefore they should be supplied with emergency kits both for adults and newborns and trained in their use. Only half of the facilities have Coartem and a quarter of the facilities surveyed lack Iron tablets. Zinc, ORS, Vit A, Tetracycline eye ointment and other drugs for managing common childhood illnesses are in short supply. Only a quarter of the facilities had gentamycin injection to manage newborns with very severe disease. Fetoscope was available in all health centers. Except in one, all HCs have examination couch, stethoscope and sterile gloves. Most but not all HCs have functional BP apparatus, functional adult weighing scale. A quarter of the facilities had fetal Doppler and very few ANC units have received Pregnancy Wheel to help determination of gestational age. None of the HCs have ultrasound service. More than 90% of the delivery units have Partograph, disposable latex examination glove, functional baby scale. A quarter to one third of the facilities lack First stage bed, labor/delivery table, adult ventilator bag and mask, heavy duty gloves and eye shield. The followings equipment and supplies are available in less than half of the surveyed facilities; wheelchair, cervical exploration set, obstetric forceps, vacuum extractor, elbow length glove. Very few facilities have filled oxygen cylinder, IV fluids and pulse oximeter. Close to half of the facilities lack Iron or Iron folate tablets, ergometrin and hydrocortisone injection. A quarter of the surveyed facilities lack emergency drugs like diazepam injection, adrenalin injection and magnesium sulfate injection 50%. Fewer facilities have phenobarbital injection, calcium gluconate and atropine required for emergency management. Chlorhexdine ointment was rarely found. – All delivery units have neonatal resuscitation bag (250 300ml) and most have functional baby weighing scale and sterile equipment for cutting the cord. A quarter of facilities lack mucus extractor, face mask size 0 and 1, and IV cannulas. Towels for drying the babies, room thermometer, and functional oxygen cylinder are lacking in most facilities. One fifth of the facilities lack tetracycline eye ointment. 120

All HCs have antihelmetics and more than 90% of facilities zinc, paracetamol and tetracycline ointment for under five children. A quarter to half of the facilities lack relevant antibiotics and antimalarial drugs. Drugs and supplies related to rehydration service are available only in half of the facilities. Most of the primary hospitals have equipment to provide maternal health services. Gaps are observed in supplies and drugs. One third of the primary hospitals lack iron tablet, antiseptic solution, folic acid tablet and magnesium sulfate injection. And half lack, phenobarbital injection, functional weighing scale, medical waste disposal box. Pulse oximeter, stretchers, Doppler and obstetric wheels are not in several facilities. Job aids are also in short supply at service delivery points in some facilities. Three of the 7 primary hospitals have 5 or less maternity beds. One hospital has one maternity bed only. Most primary hospitals have the equipment to provide essential newborn care. However half of the newborn corners lack neonatal size face mask and oxygen bottle which basically affects the provision of resuscitation when needed. Towels are rarely available. All NICU have radiant warmer and incubator set. Only one hospital NICU has CPAP (general hospital). Equipment and supplies like, glucometer, tracheal tube, suction machines, oxygen hood, oxygen flow splitter, and LP set are lacking in most facilities. Transfusion set and vital sign monitoring system, blood gas analysis are absent in all facilities. One third to half of the facilities lack the laboratory capacity to do blood chemistry and electrolytes. Except for X- Ray service other imaging studies are not available. Half of the facilities have IMNCI related equipment and drugs. One Liter measuring container is available in only one-third of hospitals.

Quality of MNCH services (training, service components, and availability of drugs, equipment, supplies and referrals.

MNCH services are widely available at HP level. One third of the staff at HP level are Level IV HEWs trained for additional one more year. However there is no job description – classification between the two types of HEW Level III and Level IV. Not all HP are fully staffed as per the national recommendation. Equipment, drugs and supplies for quality MNCH services are lacking in good number of HPs. Overall one can say the service readiness of the HP to provide quality MNCH service requires attention and support. The fact that the ANC and PNC attendance rates are increasing, making all effort to improve the service readiness is very essential. The majority of HPs have access to referral services which is very encouraging. Lack of electric power supply definitely hampers the level of service provision.

In terms of staffing at HC level, both for maternal and child health service provisions the major work forces are diploma midwives and diploma clinical nurses. Most health workers have received training in the respective service area. The BEmONC training focused predominantly on midwives while diploma clinical nurses are still responsible for provision of maternal services at all service delivery points. Services provided to pregnant and women in labor is not available in all facilities. Only two thirds of the facilities determine blood 121

group and less than half measure hemoglobin or hematocrit and do VDRL test. Very few provide inpatient services for pregnant women with complication and primarily rely on the referral system. Emergency equipment, drug and supplies are lacking in a sizeable number of facilities both for maternal and child health services that could make providing lifesaving interventions a challenge and compromising the quality of services to be provided. Only close to half of the facilities have functional newborn corner though still lacking some of the components like oxygen, radiant heater etc., which could show that readiness to provide quality essential newborn care is way behind. Despite the availability of IMNCI services in all facilities, the observed shortage of equipment, drugs and supplies indicate and gap in the quality of service provided. The readiness to manage dehydration is also inadequate. Overall the assessment indicated despite the availability of maternal and child health services there are gaps in readiness to provide quality maternal and child health services in the surveyed health centers. In most primary hospitals, maternal health services are provided predominantly with midwives. None of the hospitals are staffed by OBGY specialist or EOS trained GPs that could affect the quality of services provided. The good part is all facilities have staff trained on BEmONC. Operative delivery services is provided in all hospitals and two third have blood transfusion services. Shortages of drugs and supplies are observed in several facilities. It appears more is needed to attain a higher quality of services in terms of manpower, drugs, supplies and equipment. There are referral systems established at all levels, which is very encouraging. Child health services are available in all the primary hospitals. Like the maternal services, child health services are mainly provided by midwives and clinical nurses. None of the hospitals have pediatrician including at the NICUs and the number of GPs is limited. All the NICU are level I units. At least the units should be staffed by a pediatrician to be level II NICU not taking account the lack of certain equipment like vital sign monitors, transfusion sets and related services. Emergency related equipment, supplies and drugs are particularly lacking in several facilities. Critical laboratory services are available in few facilities. Similar to the maternal services there are established systems for referring children in need of further treatment.

Recommendations In most facilities maternal health services are provided by nurses. It will be prudent to provide ongoing trainings, frequent supportive supervision and mentoring as well as periodic experience sharing assignments to higher level health facilities. In addition assigning more qualified or trained staff should be considered. For example, even if supplied the existing staff will face challenges in interpreting advance laboratory investigations such as blood gas, blood chemistries and imaging study results. Routine and frequent staff rotation shall be avoided as this makes it difficult to see the impact of trainings and refresher training and it is expensive to train everybody on all areas of expertise.

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There shall be a strong, consistent and accountable system of distribution of supplies and drugs to address shortages and disparities between facilities. The established system to facilitate referrals between facilities is very good and the support shall continue to sustain the system. Guidelines and job aids shall be provided and personnel doing supportive supervision shall ensure its placement at service delivery points.

5.8 Findings related to Objective 9: Identify critical challenges with regard to MNCH services utilization both from demand and supply side The following major critical challenges were identified

5.8.1 Challenges of lack of awareness

The participants acknowledged that there is increased awareness on MHCH services due to mainly the efforts of HEWs and HDAs. But, still there is awareness gap in the community, families and the mothers. For example, MNCH and nutrition coordinator at Amaro Woreda health office reported that new services like CBNC and ICCM are not well promoted in some areas.

5.8.2 Challenges of accessibility of health institutions

The government has constructed health posts in the kebeles to make basic health services accessible to the community. While this is appreciated by the community, it was mentioned by participants that still some kebeles are wide that considerable number of the community members may not easily reach the health posts. For this reason, some communities are demanding for constructing more health posts in their kebeles. The problem gets severe when mothers and children are required to get the services in the health centers and hospitals. Good example mentioned was delivery service. Previously health posts were mandated to provide delivery service. Now health posts are not allowed to provide delivery service.

Mothers have to go to health centers to give birth. Most of the health centers are far from the rural community. Either mothers have to stay in the maternity waiting rooms for some days before delivery or they have to go fast to health centers when labor starts. For mothers, waiting in the maternity waiting rooms has challenges. When labor starts, going to the health centers for delivery is a huge challenge for women who live in rural areas. Since access to road is a problem for most places, they have to be carried by people until they reach to the roads. Even after reaching the roads, getting ambulance service is a challenge since the number of ambulances is limited in each woreda. Since there is shortage of ambulances, ambulances may not come quickly to pick the laboring mother. The family has to lease a car or bajaj to take her to the health center which is expensive for most families. Mobile network problem is another challenge to call ambulances and some ambulance drivers may also 123

’ switch off their mobiles or don t answer their calls, according to the informants. Because of all these challenges, there are significant numbers of mothers who give birth at home or even in the ambulances or leased car. This delay will affect the health of mothers and the fetus adversely. With regard to ambulance service, the community is also requesting if the government allow ambulances to return the mother and baby to their home after delivering in health institutions.

Since access to health centers is a problem for mothers in labor, some participants raised the issue of re-mandating the HEWs to provide delivery service. Related to this, one of the HDA “ participants of FGD in Amaro Woreda of Segen Zone emphasized the issue by saying We ’ always question why always pregnancy checkups in the health post? Why we don t have delivery services at the health post? Why we are always sending the mother to the health center instead of getting the service in the health post? Why the necessary facility for delivery ” is not available here in our health post, is our question? .

5.8.3 Challenges of availability of MNCH services, equipments, drugs, and other supplies

Many availability issues were raised. Health posts are closed when both of the HEWs are not around for different reasons like attending trainings elsewhere. One of the availability challenges is unavailability of delivery services in the health posts. Laboratory services are not also complete in some health centers or the service is totally absent. Lack of equipment, drugs and supplies are also reported by most participants. Examples of equipments which are not available in the health centers include suction machine, radiant warmer, autoclave, and weight scale. Drugs like gentamycin, ORS, and zinc are not continuously available in the health posts. People are asking why drugs absent in public health institutions are available in private pharmacies?. They also complained on the costs of drugs available in the private pharmacies. Other supplies are also short in the health institutions. A nurse from one of the health centers from Bench Maji Zone seriously complained on the availability of gloves by “ saying ...There are three mothers now in the waiting room who may deliver tomorrow or ’ later but we don t have surgical glove. ...You can imagine how much we are risking ourselves ” by attending deliveries without gloves . It was also reported that some drugs are send to health institutions when they are near expiry. The lengthy process of drug and supply procurement is also raised.

5.8.4 Challenges of adequacy of rooms in health institutions

Shortage of rooms is raised in most health institutions from health posts to hospitals in all the zones. Because of shortage of rooms, health professionals are obliged to provide different services in the same room. An informant from one of the health centers in Bench Maji zone “ reported ...The other problem is shortage of rooms. Family planning, ANC, delivery and ” PNC services are provided in one room. Under-five and adult OPDs are also in one room . 124

5.8.5 Challenges related to maternity waiting rooms

For mothers, waiting in the maternity waiting rooms is a huge challenge. Mothers have big responsibility in the family that they have to cook food and do other businesses in the house. Hence, their responsibility in the house will prevent them from going and staying in the maternity waiting rooms. Some husbands are not also supportive of the idea of staying in the maternity waiting rooms. The other challenge for mothers is lack of food and facilities in the maternity waiting rooms. This is the major problem mentioned by most participants of the qualitative study. In some communities, they contribute money and cereals for mothers who shall stay at the maternity waiting rooms. Since there are different obstacles for the pregnant women to stay at the maternity waiting rooms, they stay at home until labor starts. There are also occasions when mothers who stayed in the maternity waiting rooms for some days have gone back home before delivery since the conditions are not convenient to them. All participants requested to give more emphasis to maternity waiting rooms by all stakeholders including NGOs.

5.8.6 Challenges of availability of skilled man power

The number of people utilizing the services in the health institutions in general has increased. Mothers also want all services given in the health institution they visited. But, it was mentioned that the number of clients and number of staff working in the health institutions is not proportional. Health professionals feel that they are overstretched. Shortage of staff is a problem at each level of health institution. The need for in-service training of newly assigned staff was mentioned by most participants. In general, participants reported that training on a wide range of topics is needed including IMNCI, BEmONC, CEmONC, ANC, PMTCT, family planning, EPI etc. The other challenge health institutions are facing is high staff turnover. Emphasizing the issue of staff turnover, one of the kebele administrators in Meinit “ Goldya Woreda of Bench Maji Zone expressed his observation by saying There is shortage of health professionals. There is high staff turnover. They do not stay here more than two ’ years. I do not know their problem. You couldn t get a staff that stayed here two or more ” years . Lack of supervision is also a problem that compromised quality of the services.

5.8.7 Challenges of staff behaviour

While it was noticed that staff in the health institutions are less in number compared to the work they are expected to do, informants have observed some problems related to staff behaviour. This was especially significant in the health centers. There are some staffs that are not available in their work place, not doing their job properly when they are available, and not friendly to their clients.

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5.8.8 Challenges related to culture and religion

Participants mentioned that there are cultural influences on utilization of MNCH services. In some communities male birth attendants are not accepted. The MNCH expert at Segen Zone, for example, mentioned that in some pastoralist communities of Segen Zone, male birth attendants are not accepted. It is also a challenge in some other places. Because of this, professionals from health centers reported that most of the birth attendants now in the health centers are females. In addition to the delivery service, family planning is the other maternal health service which is not utilized well due to cultural and religious reasons. Some Muslims are not using family planning methods attributing their reason to religion. Related to culture, an informant from one of the health centers in Meinit Goldeya Woreda, Bench Maji Zone “ reported the shyness of women during delivery service by saying ...When we see utilization, ANC is good and majority of pregnant women attend ANC one to four times. However, majority of them deliver in their homes. There is attitudinal problem. When we try to perform PV diagnosis, they may sometimes run away and go to their home. There is little increase in the number of mothers delivering at health centers since I came here. In general there is a big ” problem in institutional delivery. We have been doing community mobilization . In remote areas, elders like grand fathers and grand mothers influence mothers to deliver at home. In pastoralist areas, health institution deliver is not common. Culture is also mentioned as one of the factor that influences PNC utilization. Influence of religion on family planning use is also reported but informants are not clear whether the religion really prohibits using family planning methods. A health extension worker from Jimma Zone expressed her confusion by “ ’ saying ...Some do not use family planning. I don t know why they are not using. It may be related to religion. Sometimes those who follow Sharia use family planning. Some do not ” use... .

5.8.9 Challenges within the family

Mothers have a lot of responsibility in the family including cooking food, washing clothes, managing the family etc. Some mothers may not get MNCH services due to lack of awareness. Some may not utilize MNCH services even though they have the awareness due to different challenges. The challenges include economic problem, absence of another adult who will care the family, and some husbands do not support the mothers to get the different MNCH services. Especially, if the mother is pregnant and lives in remote places, deciding to wait in the maternity waiting rooms is challenging.

5.8.10 Challenges related to water and electricity

Water shortage was reported as a major problem of health institutions. This compromises all services but highly compromise the delivery services. Added to the shortage of water, the material used for the floor are not easily cleanable in most health institutions. An informant “ from one of the health centers in Dedo Woreda, Jimma zone said Our delivery room is not ” ceramic. It is difficult to clean. So we need ceramic . Lack of electricity or frequent

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interruption of electric power also compromises the services given by health professionals. The effect is more serious in health institutions that do not have generator.

5.8.11 Challenges of communication

In some areas health workers do not speak the local language which makes communication between the health professionals and clients difficult. Health information provided by the health workers may not be easily understood by the clients. In addition, mobile network problem is a challenge especially if ambulances are needed for emergency services.

5.8.12 Challenges of recording and reporting

Poor recording and reporting is also raised by in-depth interview informants from zone and woreda health departments. They complained that some health institutions are not properly recording the services they have given. Some also do not send reports timely and the report is incomplete.

5.8.13 Conclusion and recommendation

Conclusion The major challenges identified were lack of awareness; inaccessibility of health institutions; unavailability of MNCH services, equipment, drugs, and other supplies; lack of rooms; unavailability of maternity waiting rooms and lack of food and facilities in the maternity waiting rooms; shortage of skilled man power; staff behaviour problems; culture and religion influences on utilization of MNCH services; challenges within the family; lack of water and electricity; communication challenges; and problems related to recording and reporting.

Recommendation The following are recommended to address the different critical challenges  Awareness creation using different strategies of advocacy, communication and social mobilization  Involving religious leaders and other influential people in the community in advocacy, communication and social mobilization  Counselling family members of women and children so that they support mothers and children to seek MNCH services  Construction of health institutions close to the community to make services accessible  Availing sufficient number of ambulances  Construction of roads and availing other infrastructure like water and electricity  Construction of sufficient number of rooms in the health institutions  Construction of maternity waiting areas in health centers and providing sufficient food and facilities to the mothers 127

 Employing sufficient number of health professionals and providing training to the staff on different MNCH components  Advising and controlling the staff so that they ethically serve their clients  Supportive supervision

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6 References

1. (Ethiopia), C.S.A., Ethiopia Demographic and Health Survey 2016: Key Indicators Report, 2016, Central Statistical Agency Addis Ababa, Ethiopia. 2. UNICEF, Levels & Trends in Child Mortality. Report 2015, 2015, UNICEF. 3. Health Sector Transformation Plan, 2015. 4. Ethiopia Demographic and Health Survey 2016. Key Indicators Report, 2016, Central Statistical Agency, Addis Ababa, Ethiopia: Addis Ababa. 5. Berhanu, D. and B. Avan, Community Based Newborn Care: Baseline report summary, Ethiopia October 2014., 2014, IDEAS, London School of Hygiene & Tropical Medicine: London. 6. Ending Preventable Child and Maternal Deaths. 2016 [cited 2016 Sept 20]; Available from: www.apromiserenewed.org/countries/ethiopia. – 7. Population Projection of Ethiopia for All Regions At Wereda Level from 2014 2017, C.S. Agency, Editor August 2013, Federal Democratic Republic of Ethiopia Central Statistical Agency: Addis Ababa.

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