A’AGO PROJECT - IMPROVING SEXUAL AND REPRODUCTIVE HEALTH STATUS OF AFARI YOUNG PEOPLE
SECOND YEAR ANNUAL PROGRESS REPORT (JULY 2018-JUNE 2019)
Submitted to: Embassy of Kingdom of the Netherlands, Addis Ababa, Ethiopia
Submitted by: EngenderHealth, Inc
September 2019
EngenderHealth A’AGO Project, Yr 2 Annual Report, July 2018–June 2019
I. Contents I. Contents ...... ii II. Acronyms ...... ii III. Project Profile...... iii IV. Executive Summary ...... iv V. Introduction ...... 1 VI. Goal and Objectives ...... 2 VII. Major planned activities accomplished by objective ...... 2 1. Objective 1: Increase demand for SRH information and services to youth and adolescents ...... 2 2. Objective 2: Increase access to quality sexual and reproductive health (SHR) services ...... 10 3. Objective 3: Improve the enabling environment for youth and adolescents to exercise their SRH entitlement ...... 18 4. Monitoring, Evaluation and Learning ...... 21 VIII. Lessons Learnt and Success factors ...... 23 IX. Challenges encountered and measures taken ...... 24 X. Annexes: ...... 27 Annex 1: A'ago project year 2 annual plan and achievement summary, July 2018 – June 2019...... 27 Annex 2: Contraception and CAC services provided by age and Sex category in A’ago supported health facilities, July 2019- June 2019 ...... 31
EngenderHealth A’AGO Project, Yr 2 Annual Report, July 2018–June 2019 II. Acronyms
ANC Ante Natal Care AY Adolescent and Youth AYH Adolescent and Youth Health AYSRH Adolescent and Youth Sexual and Reproductive Health BEmONC Basic Emergency Obstetric and Neonatal Care CC Comprehensive Contraception CAC Comprehensive Abortion Care CMC Clinical Monitoring and Coaching CSE Comprehensive Sexuality Education DHIS District Health Information System FGM Female Genital mutilation FMOH Federal Ministry of Health HC Health Center HEWs Health Extension Workers HIV Human Immune Virus HMIS Health Management Information System HQ Head Semimanual HP Health Post HW Health Worker IPFS Individual Providers follow up and Support IUCD Intrauterine Contraceptive Device LAFP Long acting Family Planning LARC Long Acting and Reversible contraceptive MA Medical Abortion MHM Menstrual Hygiene Management PHCU Primary Health Care Unit PMTCT Prevention of Mother to Child Transmission PNC Post Nata Care PTFS Post Training Follow up and Support RBI Rapid Breakthrough Initiative SAC Safe Abortion Care service SOJT Structured on the Job Training SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health Right STIs Sexually Transmitted Infections WDA Women Development Armies WSWM World Starts With Me WTP Woreda Transformation Plan YFS Youth Friendly Services
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III. Project Profile
Table 1: A’AGO Project Profile
1.1. Name of project Lead Partner: EngenderHealth Inc. 1.2. Contact person: Jemal Kassaw, EngenderHealth Ethiopia, Country Representative 1.3. Project consortium partners: EngenderHealth Inc, Amref Health Africa, Triggerise and Philips Health Africa
1.4. Name of Project: A’ago Project – Improving Sexual and Reproductive health status of Afar Young People.
1.5. Project Activity No: 4000000122 1.6. Project Period: September 2017- August 2021 1.7. Reporting period: July 2018- June 2019 1.8. Target Country: Ethiopia 1.9. Target Region Originally in Afar and expansion in Oromia, Amhara and SNNP Regions to expand access for comprehensive abortion care (CAC)
Beneficiary / Stakeholder Description Total Beneficiary
Total Target population All age 399,700 Adolescents and Youth Young People 92,500
1.10. Final beneficiaries &/or target Districts # of Districts 49 groups (if different) (including # of women and men): Private Health Facilities Private Clinics 34 Public Health Facilities Health Centers and 125 Hospitals Health Posts 103 Schools Schools 34
1.10: Project Budget 11,040,274 USD
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IV. Executive Summary
This report comprises year two (July 2018-June 2019) A’ago project key achievements implemented by partners namely: EngenderHealth, Amref Health Africa, Triggerise and Philips Africa. The report summarizes project supported demand creation, quality SRH service expansion, creating an enabling environment and, monitoring evaluation and learning.
As part of the effort to increase awareness and demand for SRH among adolescent and youth, comprehensive sexuality education (CSE) was successfully initiated in 30 schools (21 primary schools and 9 high schools). Following which, a total of 1,016 students have been registered for CSE, and 967 (64% female) students completed the course in the reporting period. To facilitate community engagement towards adolescent and youth SRH services; 711 Youth Facilitators, Traditional birth attendants (TBAs), Women Development Army’s (WDAs), Religious Leaders and Health extension Workers (HEWs) were trained and supported to actively engage in awareness and demand creation for SRH services. Community-Facility referral linkages were also strengthened across project areas, with more than 12,000 clients referred and served for different SRH services. As a result of project awareness creation effort, young people and community representatives have also started to strongly challenge some of the rampant socio- cultural barriers to SRHR.
On supply side, the project has introduced integrated comprehensive contraception (CC) and comprehensive abortion care (CAC) services at 36 public health facilities (11 private clinics). On the other hand, Basic emergency Obstetric and Neonatal Health Care (BEmONC) service is strengthened at 11 public health facilities. As a result, uptake of CC, CAC and post-natal care (PNC) were significantly improved where 7,177 (207% of 3,464 clients planned for CC), 554 (146% of 380 clients planned for CAC) and 1,399 (195% of 718 clients planned for PNC) were served at project supported sites. As BEmONC services required significant time to ensure service readiness (service initiation was achieved in the fourth quarter); service uptake for ANC and delivery were relatively lower but increasing over time.
To create an enabling environment for SRHR, different community-level structures were strengthened and community gatekeepers trained and supported. Besides, to create buy-in for SRHR from high level political and community leaders, regional forums and safe motherhood workshops were support. Major stakeholders from the regional public sectors have conducted joint supportive supervision among project sites both at community and facility levels and provided their feedback to strengthen the existing support the project is providing to the region.
During the reporting period, the project has also encountered challenges; including security problem, flood and draught, weak community and HEWs structure, high staff turnover among government facilities and delays in purchase of medical equipment’s. The project partners has exerted efforts to address these challenges and ensured the successful implementation of the project. Generally, the project progress has significantly expanded access to SRHR information and service to the public in general and young people in particular, serving a total of 33,557 clients. The major success factors in the reporting period include competency based clinical training supported by strong clinical mentoring, use of diversified community engagement approaches and close coordination with government partners. The project in the reporting period has utilized a total of 3,103,448 USD.
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V. Introduction
Ethiopia has managed to register promising progress in achieving most of the Millennium Development Goals (MDGs). Progress in Maternal, Neonatal and Child Health (MNCH) and Sexual and Reproductive Health (SRH) relatively has shown progressive improvement in the last two decades. However, the country has continued to face critical challenges in reducing maternal mortality and ensuring equitable access to quality SRH service.
The Government of Ethiopia, recognizing the burden of high rate of the maternal mortality and related SRH problems has made reproductive and maternal health one of its priorities. The Health Sector Transformation Plan (HSTP 2016-2020) through its transformative agenda further emphasized the need to ensuring equity and quality in health care and creating a caring, respectful and compassionate health workforce. However, these are all critical elements that are lacking in regions like Afar. Furthermore, access to safe abortion across the country is limited by a range of barriers including restriction from the US government Mexico City Policy, reinstated as Preventing Life under Global Health Assistance (PLGHA) in 2017.
In light of this fact, EngenderHealth has been supporting the Government of Ethiopia in expanding access for a range of SRH services across seven regions and two city administrations. Building on this work, EngenderHealth with funding and collaboration from the Embassy of the Kingdom of the Netherlands (EKN), in September 2017, has initiated the A’AGO project in Afar. A’ago (pronounced “Aha’ago”, in Afari, means “Hope”: Hope for adolescent and youth; girls and young women ultimately leading to healthy, empowered and productive young people in Afar. EngenderHealth together with its consortium partners, Amref Health Africa, Triggerise and Philips Healthcare Africa brought combined expertise and experience in community-based intervention, technical capacity building of health facilities, and innovations in technology. Through this partnership, the consortium envision to expand access to quality sexual and reproductive health and rights (SRHR) information and services to adolescent and youth in Afar.
The project in the first two years period has been implemented in 14 districts across four zones in Afar region. On the other hand, with additional funding EKN granted for EngenderHealth, the project is expanding access to safe abortion care at additional 35 districts supported in Oromia, Amhara and Southern Nations, Nationalities and Peoples Regions) region. The expansion is primarily to bridge the gaps in access for safe abortion care at USAID Transform Program supported sites.
This report presents the project implementation progress in the second year of the project period. It summarizes project annual accomplishments, highlights the challenges faced and solutions sought as well lessons learnt. Detail achievements are organized under three major categories, namely: demand creation, quality SRH service provision, enabling environment and monitoring, evaluation and learning. Major challenges encountered in the course of project implementation, major successes and associated factors are provided. Comparison of annual physical and financial plan vs achievement are provided in the annex sections and separate financial report.
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VI. Goal and Objectives
The goal of the A’AGO project is to contribute to the improvement of the sexual and reproductive health (SRH) outcomes of young people ultimately leading to healthy, productive and empowered adolescents and youth. Project objectives
The project has the following objectives: To increase demand for SRHR information and service among young people and their communities; To increase access to and quality of sexual and reproductive health (SRH) services, and To improve the enabling environment for youth and adolescents including girls and young women to exercise their SRH entitlements
VII. Major planned activities accomplished by objective
1. Objective 1: Increase demand for SRH information and services to youth and adolescents
1.1. Out of school SRHR interventions for adolescents and youth
1.1.1. TOT training for Health Extension Workers and their Supervisors on AYH A training of trainers (TOT) was arranged as an entry point to cascade AYSRH service for public health care providers and A’ago project staff. The purpose of the training was to improve the facilitation skills of trainees to organize community-based AYSRH dialogues, to be undertaken in project intervention communities. The training was provided for 300 HEWs selected from project targeted district health offices while the rest were project staff. They were assigned by respective district health offices to closely work with the project and thereby ensure active participation of youth groups and reasonable gender mix in their respective localities. The training was conducted using the family health card (a standard tool developed by the FMOH) which was designed for engagement at a community level.
1.1.2. Fiema groups1 training on CSE (Meharebe version 2) Out of school youth in the Afar context account for a large proportion of the population and a majority of them live in rural communities. Though young people account for a significant proportion, they receive little SRHR information and require special attention when expanding access to quality SRH information and services. The project has planned and is implementing different strategies to reach out this large group through comprehensive sexuality education and peer dialogue sessions to increase knowledge of young people on comprehensive sexuality education; educate their peer in their respective localities and organize regular dialogues sessions with close support from A ’ago project and local partners (HEWs and the Women Development Armies).
1Fiema groups: Traditional Youth group structure in Afar community 2 Meharebe version: CSE curriculum for out of school youth adapted from Word Strat with Me (WSWM) CSE curriculum. 2
The Meharebe curriculum, developed by Armed Health Africa, covers 15 CSE lessons -and is delivered in the way that best suits facilitators to develop facilitation skills and address the cultural and behavioral barriers. The project hosted training for curriculum facilitators where four facilitators from each youth groups attended. A total of 214 facilitators (97 females) from nine districts composed of youth group representatives (four from each youth group), and HEWs from their respective Kebele’s attended the training. This makes the total number of youth/Fiema groups 38 during year two of the project period.
1.1.3. Support youth/Fiema peer dialogue sessions on SRH (Coffee Ceremony) Following the facilitators training, educators/facilitators and HEWs have begun to organize Fiema/youth dialogue sessions using the Meharebe manual with close support from the project officers. In this reporting period, 38 youth/Fiema groups organized 125 dialogue sessions and a total of 1,438 (594 female) young people were reached with information on SRHR. Supports provided to run successful dialogue sessions include: material and technical gaps filling, onsite mentorship to HEWs and trained facilitators, onsite technical feedbacks for both HEWs and facilitators on their facilitation skill and discussing with local actors such as representatives from Kebele, Health (HPs) and Health centers (HCs) so that they would give due attention to and support the youth groups.
Figure 1: youth dialogue participants, Awash Fentale for Meharebe life skill training
Despite the focus given on the Fiema youth groups, only 9 youth groups with 226 (110 female) members from all intervention districts have been able to complete the lessons of CSE (of Meharebe version) which is less than 23% achievement of the year. The project has found that most out of school youth in communities are found to be illiterate and engaging them with formal curriculum like Meharebe is quite challenging. Similarly, youth in the pastoral context are engaged in day-to-day economic activities, and it is difficult to get them to attend consecutive sessions over a period of many weeks. Even those youth groups found to be more organized have been reluctant to attend dialogue sessions. As a result, the project team is in discussions about redesigning and adopting alternative community dialogue approaches, which are not as time intensive. For the reporting year, social mobilization activities (market place campaigns) combined with health bazar have been considered as alternative means to address young people and the wider pastoral community. We found that, the latter approach is more suitable to address target groups and the community at large, while documenting lessons from effective Fiema groups.
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1.1.4. Married and pregnant adolescent couple group conversation on SRH Married couples and pregnant adolescents and youth conference has been conducted at health post level under the leadership and coordination of (HEWs). These clients were initially identified by HEWs and WDAs through a house-to-house visit strategy in the community. Following the identification, they advised pregnant mothers to initiate ANC follow-up, and invited them to attend pregnant mothers dialogue sessions conducted within the health post.
Technical support was provided by the project in collaboration with Primary Health Care Unit (PHCU) focal persons. In most of the cases, PHCU assigned midwives and HEWs facilitated the conferences. A variety of topics/issues on pregnancy, delivery and post-natal care were raised and discussed. During the discussions, women also shared their experiences with their peers, learned from each other and created informal community networks through which information and support were nurtured.
In the reporting period, 3 districts (Argoba, Awash Fentale, and Amibara in zone 3) were actively managing the dialogue session through their PHCU linkage. As a result, 26 couple group conversation sessions were conducted in the above three districts. In doing so, some positive changes have been observed in PHCUs. Health seeking behavior of mothers have been improved much better than the initial phase of implementation due to WDAs engagement. For instance, in Boloyta Health Center alone, the average facility based delivery number per month increased from 2-3 per month to 9-10 per month.
1.1.5. HEWs’ and Feima facilitators review meeting and refresher training Supporting HEWs and Fiema/Youth group facilitators to review their performance helps in identifying major challenges and successes in cascading SRH dialogue sessions. The review also involves key project actors from different sectors, such as: the education sector, health office, women and children office and youth offices. These reviews are conducted in two approaches, namely district level and cluster level review meetings. The district level review is conducted at each respective district/Woreda involving all the health actors (HPs, HCs, youth/Fiema, WDA representatives and district officials). While the cluster reviews are conducted among PHCUs to strengthen linkage where the Woreda Transformation Plan (WTP) is embarked on. The WTP is one of the four transformation Agenda in the health sector transformation plan which aims in narrowing the gap between the high and low performing woredas through creating model Kebeles, financial protection through Community based Health Insurance and creating a network of high performing PHCUs. It is known that Amibara, Awash Fentale and Argoba Woredas are the three districts implementing the Woreda Transformation Plan that the region requested A’ago project alignment and support. Harmonizing activities with Woreda plan is very important to support PHCU linkage (HC-HP and HP-community linkages).
To this end, 13 PHCUs and five Woreda based review meetings were conducted in all districts. A total of 754 (310 females) participants from HEWs, HWs (working at HP level), out of school youth, WDA members, teachers, mobile health team as well as selected HC and Woreda health office staffs participated in these review meetings. In all review meetings HEW/HW have presented their respective progress reports for discussion.
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1.2. Increasing access to SRH information to in school youth 1.2.1. TOT training on WSWM (CSE) for A’ago Team and Partners Comprehensive sexuality education within a safe and learning environment alongside with creating access to service delivery has a documented positive effect on the health of young people. Providing CSE to in-school students is one of the modalities adopted to reach adolescent and young people. Initially, to kickoff world starts with me (WSWM) program, a six days TOT training was provided for representatives of Woreda education offices and A’ago staff to give quick insight of the program and let partners actively engage and collaborate in support of the program throughout the implementation period. A total of 17 participants attended the training from nine districts education offices and A’ago staffs.
1.2.2. WSWM curriculum training for teachers Initiating comprehensive sexuality education approaches have faced various challenges from religious communities, schoolteachers, parents and leaders at various level in different counties. Evidences tell us that a well-designed CSE program need special attention before the program launches to the schools. In line with this, the project developed a rapid school assessment tool and initial assessment was conducted in 21 elementary and 9 secondary schools. The major focus areas for the assessment include; availability of computer room, number of teachers, number of students (gender and age disaggregated), vulnerability of the school to SRHR related problems, existing SRHR problems like early marriage, unintended pregnancy, and school dropouts (based on qualitative information) and ability to reach pastoralist adolescent and youth.
Following the WSWM training of trainers, comprehensive Sexuality Education training program was organized for teachers proposed to facilitate WSWM session in school SRHR centers. The selection of teacher’s trainees was made through discussion with the school, where five representatives including the school biology teacher, ICT teacher, Gender club focal person, SRH club focal person, the school principal and school club coordinator were identified to be trained. In this teachers training, 95 (32% female) participants from 21 primary schools and 45 teachers (7 females) from 9 secondary schools were trained and equipped with basic facilitation skills for WSWM CSE at school.
Among the selected schools, nine of the primary schools are located in remote areas where there is no access to electric power supply. The project delivered paper-based version of the CSE curriculum to best fit the situation. The training aims to improve their knowledge on sexual reproductive health, develop positive attitude towards AYSRH, and improve facilitation skills of trainees.
Before the actual startup of CSE implementation, trained teachers across all the 21 primary and 9 secondary schools organized whole site school orientation to the school community members. This orientation has helped in ensuring that school communities are well informed and actively engaged in supporting SRHR information and service for their students. At a primary school level, 224 (99-female) participants have attended the sensitization workshop for two & half days, whereas at high school level, 258 (12 females) participants attended the orientation.
The project has supported both the in school and out of school interventions with different materials and equipment to cascade the CSE and community engagement interventions. Some of the equipment and basic furniture provided include Televisions, drums, Chases and generator
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(for health centers), computers (health center), horn speakers and wireless microphones (schools), amplifiers, wireless speakers, horn speakers (for out of school), examination bed (health center), microscope and ambubags (health centers). A total of 13 primary schools, and 9 high schools were completely furnished with computers. Similarly, 25 health centers were equipped and supplied with various medical supplies and equipment based on their demand.
Figure 2: Distribution of computers and YFS materials for schools and health facilities, 2018.
1.2.3. Comprehensive Sexuality Education Training for Students In the second year of the project, 1016 students (649 females) have registered for WSWM/CSE intervention. Out of these, 967 (97% females) have completed the course, and graduated in their respective schools. The graduation of those who completed helps to recognize their continued effort and to encourage the rest of the school students to register for the upcoming CSE training. Selected students from the graduated ones will be further trained to conduct peer education sessions to reach more students on SRHR education and provide referral services for SRH. Graduating students managed to organize exhibitions and disseminate SRHR message to school communities, government bodies and to their parents. The project also used these graduating events as an opportunity to disseminate SRHR information to the community.
Figure 3. CSE graduation at Sabure secondary school, June 2019
In most of the schools where CSE is conducted, the project has noted that positive behavioral changes have been observed among students towards SRHR, such as expressing their ideas freely on SRHR matters, developing confidence to ask for feminine products like sanitary pads.
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1.2.4. Review of in school interventions As part of in school CSE intervention, the project planned to host review meetings with partners to evaluate progress, provide required support and address challenges encountered during the course of implementation. In line with this, two different review meetings have been adopted to review progress: school based3 and cluster level4 biannual review meetings.
At the primary school level, in the reporting period, six primary schools were supported for school-based review meeting in which, 29 (21 Male and 8 Female) teachers attended the discussions in their respective schools. Whereas, for biannual review meetings all 21 schools were addressed in cluster review meeting. In total, 86 (35-female) attendees participated on the biannual review meeting. On the other hand, at least one round school level review meeting and supportive supervisions were undertaken at all the 9 secondary schools where 45 participants attended the meeting.
During the meetings, frequent power outage was raised as a main implementation challenge, where facilitators have adopted paper based Meharebe manual alternatively, especially in the primary level of schooling. For schools where electricity is a challenge, the project will continue to strengthen the Meharebe manual in the coming project implementation period.
On the other hand, following the demand creation intervention with CSE, the project has established referral system to the nearby health facilities for SRH services. In two of the secondary schools, Worer and Awash Arba, referral was initiated using the Triggerise mobile- based system (TIKO). However, because of different barriers that restrict primary school students to have access to mobile phones, the project could not scale up the system for the primary schools. Further scale up will be considered after reviewing the volume of referral and usage by the school community.
1.2.5. Girls menstrual hygiene management (MHM) initiation in school Most adolescents and youth spent almost half of their time in school. In line with this, girls' menstrual hygiene management has been identified an important SRHR issue within the project. In this regard, the project is availing sanitary pads for those who need at school level. In this year, more than four hundred fifty packs of sanitary pads were purchased and distributed to schools, 50 packs per the nine secondary schools. Similarly, noting the challenge that rural communities face, shortage of cash to purchase sanitary pads, the MHM intervention includes awareness creation and skill building to students on how to prepare a clean pad from locally made clothes.
1.3. SBCC interventions within the community 1.3.1. Adolescent youth health (AYH) training for HEWs and Health Workers. Limited access to quality youth friendly SRH services coupled with poor SRHR knowledge in pastoral areas is contributing to negative reproductive health outcomes. With the intention of increasing young people demand for reproductive health service, the project has been working
3 The review meeting targets individual schools and conducted in every school, involves the program facilitators/teachers, focal persons and education office representatives. 4 Geographically proximate schools come together to attend the meeting at cluster level so that schools would share experience and learn lessons among each other. 7 to enhance the capacity of service providers through training programs focusing on HEWs and engaging communities to increase the demand and knowledge of services. In this regard, the project organized training programs during the reporting period for 237 HEWs and health care providers on AYH and community engagement. From the total participants, the number of female attendees account for around 40% (94). After the training, HEWs were tasked with promoting and delivering AYH messages/education at community level, while district focal persons and health care providers at health centers mentor and support HEWs in close collaboration with the project team.
1.3.2. Community Engagement Trainings for HEWs and their Supervisors In selected districts of zone one and zone four, where the USAID transform health in developing regions project (T/HDRS) is being implemented, A’ago project supports expanding access to comprehensive abortion care services. In these sites, the project adopted the community engagement material developed under the ABRI project of EngenderHealth. To cascade the training, a first round of 15 experts from health facilities and regional health bureaus were trained on community engagement for three days. Following this, a two days basic community engagement training was provided for 138 HEWs, nurses and community volunteers. The ultimate goal of the trainings is to cascade community engagement interventions and expand access to SRH services in the community. The community was provided with the relevant tool to explore problems and concerns affecting their well-being; identifying priorities; and developing, implementing, and evaluating activities to address these concerns. Because of this intervention, nearly 18 community dialogue sessions in five districts have been conducted. In the third year, the project expects more dialogues sessions and referrals through the involvement of a local non-governmental organization.
1.3.3. Support local media in the production and dissemination of SRH information According to the baseline survey conducted by the project, radio is the second most preferred source of information for Afar pastoral communities next to interpersonal communication. The primary audiences of the radio program, according to the project SBCC strategic document are rural men and women comprising newly married, pregnant, lactating, in school and out-off school youth. The secondary audiences are clan leaders, religious leaders, HEWs, TBA, and WDAs.
A radio program design development workshop was conducted focusing on developing a radio program suitable for pastoral communities where the project is working in. The content was organized into content sheets that discuss specific SRHR issues required for developing episodes. The content sheets consist of; the purpose of the episode and the expected outcome of the episode broken down into what audiences should know, feel, and do after listening the episode; In total, 20 (6-female) participants from youth clubs, students, journalists, HEWs, teachers, religious leaders, clan leaders and woman affairs attended the workshop. Based on the radio program production plan, the production team will travel to Afar to make interview as part of the preparation of 15 episodes that will be broadcasted in year III.
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1.3.4. Conducting Market place campaigns and social events A two days consultative workshop was organized with community gatekeepers prior to conducting the social mobilization activities. The purpose of the workshop was to initiate and motivate gatekeepers to support social mobilization activities in their respective localities. During the event, the gatekeepers brought up different problems affecting the wellbeing of communities such as problems related to FGM, abduction and early marriage. They are keen to educate communities and promote HTP free communities.
A total of 62 (15 females) community gatekeepers from 10 Kebele of Amibara district attended the workshop. These gatekeepers comprise religious and clan leaders, Kebele chairpersons, schoolteachers, woman affair office and youth representative as well as HEWs and TBAs working in the communities.
Figure 4 Market place based social mobilization event at Kebele
After the workshop, six social mobilization events were organized in collaboration with Woreda health office and youth clubs in 6 Kebele of Amibara district. Youth clubs have provided entertaining music show, which were used as a means to mobilize the community. During all of these different events, the use of Philips Backpacks were introduced to the vast community and people were encouraged to utilize the service. In this reporting period, 4,500 (2,750 Female) beneficiaries were reached by the social mobilization, of which nearly 2,850 (1,550 female) were adolescents and youths. 1.3.5. Initiate and scale up mHealth solutions to reward behavior - Tikosystem Tikosystem-is a mobile-based ecosystem centralized around clients (young women 10 to 29 years old) and her community. The Tikosystem identifies behaviors that can be nudged using Tiko Miles as a reward to engage in the desired healthy behaviors. In A’ago project, Tiko system links the demand creation activities and information through the digital platform to the quality SRH products and services. The client, Tiko pro, and service providers are all compensated for participation and service uptake, referral of clients and confirmation of service uptake respectively. The system unifies local traders, providers and entrepreneurs in order to meet client’s needs by providing life-enhancing opportunities and rewarding positive behavior.
In the second year more than 246, 630 Tiko Miles have been issued to all the actors in the Tikosystem. The target groups (males & females were age 10 to 29 years old) earned 118, 975
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Tiko Miles for joining the Tikosystem and taking an SRH service or product and rating a service. Tiko Pros enrolled the target audience into the system and earn Tiko Miles when someone they enrolled uses a service. The Tiko Pros earned a total of 91,175 Miles. Providers working at the health centers earned Tiko miles when they provided and validated SRH services to the Rafikis in order to cover the cost of their data, and they earned 36,480 Tiko miles in the second year. To improve the referral system, the project is working in expanding the service to other districts and increasing active Tiko Pros and their earnings.
2. Objective 2: Increase access to quality sexual and reproductive health (SHR) services
2.1. Health workers capacity building 2.1.1. Basic Comprehensive Contraception (CC) and Comprehensive Abortion Care (CAC) training According to EDHS, contraceptive prevalence rate in Afar is less than 12% and the baseline study in A’ago for the specific project sites indicates 20%. The project identified gaps in contraceptive commodity supplies, health workforce capacity and infrastructure issues as some of the challenges. Similarly, access to quality contraceptive services is very low, where the project baseline information showed that, most facilities do not provide all contraceptive options. Safe abortion care and post-abortion care services were the commonly missed services in most of the A’ago sites. In response to this, in the reporting period, A’ago project has trained more than 78 health workers on CC and 37 health workers on CAC across 25 health facilities.
However, high turnover of trained health facility staff have been a challenge for the project, where more than 22 trained health workers have moved from their workplace in the past one year. To address this high turnover, the project has conducted a gap filling training and trained. 16 additional health workers on CC during the reporting period.
2.1.2. Basic Emergency Obstetric Newborn Care (BEmONC) Training Major reproductive health services in Afar are comparatively lower than the national average. This gap is not only low on contraception and CAC services, but also facility-based delivery, antenatal and postnatal, PMTCT and other related health services are all found to be lower in the project sites. Accordingly, A’ago project has identified BEmONC services as priority interventions. In this regard, 10 public health facilities were planned for initiating BEmONC services in the second year of the project. However, during facility readiness assessment, the project identified 12 health centers and training was provided for 16 health workers (9 females) from these facilities. Currently, a comprehensive BEmONC service that includes the seven signal functions namely: 1) parenteral treatment of infection (antibiotics), 2) parenteral treatment of severe pre-eclampsia/eclampsia (e.g., MgSO4), 3) treatment of PPH (e.g., uterotonics), 4) manual vacuum aspiration of retained products of conception, 5) assisted vaginal delivery (e.g., vacuum-assisted delivery), 6) Manual removal of placenta and 7) newborn resuscitation services are being provided in 12 health facilities. Since initiation of the service, 7,472 clients were served for various BEmONC services. Though post-natal care was initiated very recently, 232 clients (plan was 110) were served for both post-natal care 1 and 2.
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Figure 5 Comprehensive Abortion Care Training, Practice on models
Table 1: Health workers training for health centers and hospitals in A’ ago supported sites, 2019
Total project Type of YII SN YII Plan % plan % training Achievement (TPP) plan 1 CC 40 78 195% 140 56% 2 CAC 40 37 93% 90 41% 3 AYH 20 21 105% 120 18% 4 BEmONC 20 16 80% 70 23% Total 120 152 127% 420 36%
2.1.3. AYH Training for Health Facilities A total of 21 (10 males and 11 females) health workers from Zone 3, 4, and 5 were given basic training on adolescent and youth health (AYH) service provision. The training was conducted to strengthen adolescent and youth friendly health service provision. The government of Ethiopia recommends an integrated approach in expanding access to AYH services. However, the project has identified challenges of training limited number of health workers. We feel that if the service is integrated almost all the health workers need to be oriented on AYH service provision based on the national training material, which is costly. In this regard, the project has adopted the following recommended approaches, (1) for facilities in highly/densely populated areas, establishing a youth friendly corner where integrated services can be provided, (2) for facilities in a very rural part, where the population is sparsely populated, train focal persons and cascade whole staff orientation on AYH to expand the service.
2.1.4. Clinical standardization training The aim of this training was to ensure proper knowledge and skills on international, national and EngenderHealth’s clinical policies and guidelines. The project has trained A’ago project consortium team members and government staff on clinical standardization to ensure adherence to clinical standards on family planning and comprehensive abortion care services. It also served
11 in providing technical assistance to the A’ago project supported facilities by creating a pool of trainers on comprehensive abortion care and comprehensive contraception. A total of 23 participants selected from EngenderHealth newly recruited A’ago project staff, Amref health Africa A’ago project staff, Triggerise A’ago staff, Afar regional health bureau and Semera health science college have participated.
2.1.5. Training of health workers at health posts on comprehensive FP service Provision of family planning in pastoral context has been a challenge due to lack of knowledge and misconceptions about family planning. This has been an obstacle in expanding access to FP service delivery leading to unplanned/unwanted pregnancies. A’ago project aims to increase access to SRH services and has been working to reduce high level of unplanned/unwanted pregnancies and related complications. As part of addressing this challenges, in addition to community level awareness and demand creation, efforts are underway to avail family planning service at community level through health posts (HPs). In this regard, training on family planning services for health care providers at health post were provided for 44 (13 female) health care providers from health posts. Post training follow up reports indicate that changes have been noted immediately after the training. Some health posts have started reporting uptake of long acting family planning methods which were not ever seen at HP level before.
2.1.6. Private facilities engagement in availing SRH EngenderHealth is well known in buiding the capacity of public health facilities to avail quality SRH services. However, the private health facility remain to be a major choice for clients and it was a missed opportunity to expand SRH services. A’ago project has noted this gap and developed a plan to partner with private health facilities to expand CC and CAC services. However, as a new partnership, it took a long time to assess the private health facilities capacity, their interest in SRH services and sign memorandum of understanding beetween private health facilities, the regional health buearue and EnegnederHealth.
In this regard, a series of consultative workshops have been held with private facility owners and governmnet parners. In the first consultative meeting, 36 participants from primary, medium and higher private clinics in Afar discussed on the private health facility assessment findings. Representatives from the public regulatory bodies including Woreda health offices and regional health bureau have also attended the meeting. The objective of the meeting was to highlight the need for private health facility engagement, the capacity and needs and the project plan to work with the private facilities to avail quality SRH information and services to young peoples. Among the major issues raised in the consultative discussions were, the challenges in accessing supplies and commodities for both CC and CAC services, shortage of trained providers, weak support from Woreda and regional health bureau and limited availability of HMIS registration book.
Taking the inputs from the consultative workshop, EngenderHealth and the regional health bureau developed a private facilities engagement model to involve private health facilities in expanding access to quality CC and CAC services. Following which, a second round of consultative meeting with the private health facilities was conducted and a tripartite memorandum of understanding (MOU) agreed. In this round of consultation, 12 private health facilities (all medium clinics who were found eligible based on a facility audit) were selected for SRH service initiation. Currently, following the training and related support the project provided, 7 private health facilitates are actively engaged in providing CC. Project support will be
12 strengthened to train additional private health worker on CC and CAC, commodity support will be provided and individual providers support will be given to trained health workers to strengthen the provision of quality SRH services.
2.1.7. Private drug vendor’s orientation on SRH for referral To increase access and referral linkage for SRH services, a one-day orientation meeting was organized for 13 private drug vendor owners. In this meeting, the project has updated the participants on the current SRH situation in the region, specifically focusing on contraception and safe abortion care services. As a frontline facility supplying different medicines to clients, they have ample experience on who seek CC and SAC commodities. In this regard, they recommended expanding the service to the private health facilities, availing a better counseling and service provision as well as orientation of law enforcement bodies to improve access to these services.
2.1.8. Purchase, installation and Distribution of Philips backpacks medical kits and briefing of health workers All procured backpacks were imported in January 2019. The backpacks are of three different categories: 23 midwives plus kits, 10 outreach kits and 93 community health workers (CHWs) kit. Memagie Medical Imports PLC, a sole distributor of Philips equipment in Ethiopia, installed all items and those with defects were reported for replacement. Memagei organized a further TOT for 18 (5-female) participants selected from all project intervention districts health offices, health centers and Regional Health Bureau. We further trained 26 (7 female) health service providers and 69 (35 females) HEWS on the use of the different kits.
Hand over event and a tripartite private partnership agreement was made between Afar Regional health bureau, Philips, and Amref Health Africa with presence of the representatives from the Embassy of the Kingdom of the Netherlands in Ethiopia, the regional health bureau head, EngenderHealth, Phillisp and Amref. District and other regional bureau participants were also invited to take part of the event. Currently, facility based distribution is made to 11 health centers and 3 hospitals (Midwives Kits), 2 outreach backpack kits for 2 districts and 27 HPs (outreach back pack kits), all in Awash town, Awash Fentale, Amibara and Argoba districts.
2.1.9. Support mobile health team to deliver services Outreach services were planned to reach women, vulnerable adolescent girls, and young women living in remote communities where people are unable to get reliable health service delivery and referral systems. Some of the districts in the project site have pastoral communities who are mobile in search of a better grazing land and water for their cattle. Accordingly, strengthening the mobile outreach services is very important and was planned in A’ago project. The initial strategy was to use the existing mobile health team established by UNICEF and the regional health bureau. However, assessment of how these mobile teams functioned indicated that these groups are managed by the RHB, have a different remuneration system from the existing health system, they were also not integrated in to the lower level health structure (PHCU). Hence, the project team decided to use the PHCU structure to ensure sustainability, instead of supporting a separate structure.
In this regard, in collaboration with district health office, a separate outreach intervention is organized to provide basic health service packages and AYSRH services. The activity was
13 implemented in six Kebele of Amibara district integrated with social mobilizations activities. While social mobilizations events were organized at a given community, the mobile team established corners for service provision to serve more clients simultaneously at a time, mainly focusing on CC, ANC, PNC and child growth monitoring. All outreach services were supported by the newly introduced Philips Backpack kits, which attracted and motivated people to get the service. In the reporting year, 184 women (123% of the plan) were able to receive ANC, FP, and counselling services during the outreach programs. Out of the total people served 33 females clients were <18yrs. This achievement was made in a short period of intervention and indicates a need for the project target modification. 2.2. Quality improvement for SRH 2.2.1. Whole Site Facility Orientation Whole site facility orientation is an onsite training and discussion with health facility staff. It is intended bring all facility staff to same understanding on the needs and challenges in the provision of SRH services. It improve the knowledge of staff and promote compassionate and respectful care to provide quality services, especially CC and CAC. During this reporting period, whole site facility level orientations were undertaken at 19 health facilities with involvement of 322 health care staffs, an average of 17 staff attending the orientation per facility. The orientation created an opportunity for providers, managers and supporting staff to reflect on bottlenecks to provide quality SRH service, develop and implement plans to improve services.
2.2.2. Individual Post Training Follow Up and Support (IPFS) Individual post training follow up and support is a standard approach EngenderHealth uses to provide post training follow support for trained health workers which starts within a month following a clinical training. It is tailored to individual provider needs and continues until the individual trained provider becomes competent and confident in providing the service. IPFS not only help build competence of trained providers but also serves as a mechanism to ensure that services are initiated and continued without interruption. It contributes to the improvement of quality and coverage to essential SRH services. IPFS focuses on addressing knowledge, skill, logistic and administrative barriers that limit individual provider’s capacity to initiate or sustainably provide services after training. In lieu of this, IPFS was conducted at 23 facilities, for a total of 78 CC and 37 CAC trained providers. During this follow up, the project team has seen improvement in infection prevention practice at each health facility and service uptake, and some of the trained providers have started sharing their knowledge and skill on long acting and reversible contraceptives (LARC) to other health workers, which will further be strengthened through structured on the job trainings (SOJT).
2.2.3. Clinical Monitoring and Coaching (CMC) Clinical mentoring and coaching is a comprehensive mentorship approach to health facilities who provide services. It is conducted regularly every six month, and during routine supervision on quarterly bases. EngenderHealth program officer supporting the individual facilities usually does it. CMC is conducted based on a standard checklist incorporating detail feedback and coaching approaches that leads to recommendations and actions for improvement. In this reporting period, more than 10 health facilities have been mentored for all aspects of clinical service provision at a site to identify gaps between actual practice and clinical standards, to assess readiness and processes of the health service provision, observe procedures and provide constructive feedback and on spot technical assistance to improve quality of services.
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2.3. Strengthen infrastructure and medical supply of service delivery points 2.3.1. Purchase and supply of SRH Supplies (commodities, medical instrument and consumable supplies) The Ethiopian pharmaceutical supplies agency (EPSA) is the sole responsible organization to purchase supply of commodities and medicines to public health facilities in Ethiopia. However, the A’ago project baseline survey has identified shortages in medical equipment’s, consumable supplies and some SRH commodities, with frequent stock outs in most of Afar facilities. Accordingly, to ensure readiness of facilities and availability of essential commodities, the project consortium partners have provided gap filling supplies of various medical instruments, commodities and consumable to more than 25 health centers and a number of health posts, including the Philips backpack materials. Supplies and commodities were also supplied for private and new expansion government health facilities to initiate family planning and abortion care services. The supplies among other includes IUCD insertion and removal kits, Implant insertion and removal kits, MVA kits, MA drugs and infection prevention consumable supplies. 2.3.2. Construction/renovation to strengthen health facility infrastructure At project baseline, significant number of facilities in the project area were found with limited infrastructure that enable provision of quality SRH service. In response, the project has undertaken assessment and prioritized facilities with critical need. During this reporting period, the project has construct 6 youth friendly service rooms, 4 maternity waiting homes and 4 menstrual hygiene management rooms with four seat school latrines. However, most facilities still demand minor renovations support especially for improving infection prevention facilities. In this regard, further priorities have been set an additional support will be providing in the upcoming period.
Figure 6: Youth friendly service renovations in Sabure and Awash health centers
2.4. Annual Service Uptake (July’18-June’19) 2.4.1. Total Confirmed SRH service Referral: Ccommunity and TIKO system referral Tikosystem implementation was expanded to two additional areas during the reporting period; Logia and Mile, reaching a total four operational woredas including Awash and Amibara. Across the four Woredas, the project has register 5,903 clients (126% of the 4,681 plan for the year). Out of which, 5,739 clients (nearly two fold of the planed 2,874 clients) were referred and served for different SRH services. The over achievement is attributed to the strong follow up and support to individual health service providers, strengthening of commodity supply system, and improved quality of service. We have also noted that the baseline service was very weak and
15 modification of target is already done. Though the baseline was very low during service initiation, good quality clinical trainings, individual providers follow up and support and clinical monitoring and coaching have played significant role for improvement in service quality and the over achievement.
Analysis of the beneficiaries from the Tickosystem showed that about 64.5% of clients accessing service are women. In terms of age, 62% were young people of 19 to 24 years age, while about 13% were below 18 years of age. The improvement in participation of the lower age group might be because of the linkage and participation with school based CSE interventions.
Figure 7: Annual confirmed referral services supported by Triggerise TIKO System.
2.4.2. Comprehensive Contraception (CC0 Service
A’ago project baseline survey has indicated that access to comprehensive contraceptive service is very weak in most of the health facilities. Noting the existing situation, the project is working on demand creation and strengthening quality of services both at private and public health facilities. Currently 25 public health facilities, 44 health posts and 13 private health facilities are providing comprehensive contraception services. In the past one-year, a total of 12,830 clients were served comprehensive contraceptive services including for condoms. Nearly 6,838 of these clients used short acting and long acting and reversible contraceptive (LARC) methods, where the share of LARC is 11.86% (10.62% implant and 1.24% IUCD). As can be seen from figure 9 below, the uptake CC at project supported health facilities is improving over time. The Y-axis on the left shows the total number of implant and IUCD users (LARC users) whereas the values on the right side of the Y-axis show total number of short acting family planning services (pills, and injectable). The trend shows that the service uptake is improving across time but all services declined between Jan to Mach, 2019 because of security challenges.
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Figure 8: A’ago project CC service by short acting and LAR, July 2018-June 20189
2.4.3. Comprehensive Abortion Care Safe abortion care services are highly stigmatized and poorly accessed at public health facilities in Afar. However, most of the towns in the region are located on the main road to Djibouti, which makes adolescents and youth in the area highly vulnerable to different SRH problems including unsafe sexual practices and unwanted pregnancy. A’ago project has planned to improve access to quality CAC service, for which the project has introduced CAC at 25 health centers. In the second year, project supported facilities has served a total of 554 CAC services, of which 277 (50%) were served for safe abortion. Table below shows the details of CAC services provided by procedure and Figure 10 shows trends in CAC uptake at project supported facilities.
Table 2: A'ago project year 2 CAC service uptake by procedure (July 2018 to June 2019) Procedure SAC PAC Total MVA (Manual Vacuum Aspiration) 114 215 329 MA (Medication abortion) 163 42 205 E&C (Evacuation & Curettage) 0 17 17 D&C (Dilatation & Curettage) 0 3 3 Total 277 277 554
Figure 9: A’ago project CAC service uptake across time (July 2018 to June 2019)
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2.4.4. Post abortion Contraception/FP Uptake Pregnancy is expected to recur within two weeks after abortion services. Evidence suggests that availing post abortion contraception/family planning will reduce unwanted pregnancy by more than 80%. Accordingly, A’ago project is working to improve access to integrated safe abortion care service and post abortion contraception/FP services across all facilities. In the second year of the project, out of the total clients served for CAC (554), 331(59.7%) have adopted post abortion contraception/FP services.
2.4.5. BEmONC and other services Availability of basic emergency obstetric and neonatal care (BEmONC) is one of the indicators showing access to and quality of SRH services in a facility. According to the 2016 national BEmONC assessment5, nationally 14% of facilities provide BEmONC service, which was less than 1% in Afar. Accordingly, A’ago project has prioritized expanding BEmONC service at 20 public health facilities. In the second year, 12 facilities have initiated the service and 7,452 clients were served for different BEmONC service, see Table 2 bellow.
Table 2: BEmONC and other SRH service uptake t A’ago project supported sites, July 2018 to June 2019
Services 15-19 20-24 25-29 30-49 Total ANC 1+ 305 554 507 329 1695 ANC 4+ 84 162 178 106 530 Skilled Birth Attendance 121 196 239 121 677 PNC 1 88 176 198 807 1269 PNC2+ 22 56 32 20 130 STIs Screened 177 291 294 208 970 STIs Treated 5 18 16 7 46 PMTCT Test 184 374 392 240 1190 PMTCT treatment 3 2 3 1 6 FGM Counseling 159 337 216 110 822 FGM De-infibulation 24 44 44 25 137
Total 1,172 2,210 2,119 1,974 7,472
3. Objective 3: Improve the enabling environment for youth and adolescents to exercise their SRH entitlement
3.1 Strengthen community level structure 3.1.1 Support the functioning/establishment of social mobilization team at Kebele level Community structures and volunteers such as Women Development Army (WDA), Social Mobilization Team (SMT), Traditional Birth Attendants (TBAs) and others are key actors to support project implementation at community level. In agrarian setup, Government of Ethiopia
5 ETHIOPIAN Emergency Obstetric and Newborn Care (EmONC) Assessment 2016
18 initiated Women’s Development Army (WDA) strategy in support of the Health Extension Program (HEP). WDA team leaders support the HEWs to disseminate essential health messages and mobilize the community for key health services and health actions. This approach is helping to increase community engagement and expand health-seeking behavior in the community.
The situation in Afar is by far different from this; limited community structure is functional to support the health extension program. The project has therefore redesigned the approach and engaged local partners to either build on existing traditional community structures and/or establish new structures. To this end, in collaboration with Woreda partners, the project has established and started providing support for WDAs at 4 Woredas (Argoba, Amibara, Awash town, and Awash Fentale). So far, 274 WDA teams have been established and supported in 22 kebeles. In addition, the project supported training of 36 women (1 to 5 network leaders) at Boloyata health center and for 30 WDA leaders (1 to 5) at Sabure health center. The WDA leaders were immediately engaged in community mobilization activities in support of HEWs. As a result, 4,497 women were referred to health facilities for different SRH services.
3.1.2 Conducting SRH training for gatekeepers/ community and religious leaders, and community volunteer The other program the project embarked on during the reporting period was gate- keepers/community leaders training on SRH, which was conducted to create an enabling environment for adolescents and youth at the community level and thereby increase demand and service utilization. The training was conducted in collaboration with Woreda health offices at Awash and Dalifage towns for participants selected from all project intervention districts. Totally, 70 gatekeeper/community leaders (2.8% females) attended the training. The participation of women is law because religious and community leaders in Afar context are men. At the end of the training, participants together with Woreda health offices developed action plans to cascade actions to create enabling environment at community level.
3.1.3 Support regional forums and networking with stakeholders During the reporting period, A’ago project has provided technical and financial support for different regional level SRH forums. This include supporting annual safe motherhood celebration event, supporting revitalization of women development army in the region, and regional forum on strengthening youth interventions.
Safe motherhood Event: The 2019 safe motherhood day was celebrated in Afar in the first week of February 2019. The event was designed to sensitize high-level leaders, partners and communities on the importance of working on reduction of maternal mortality under the moto of “Let’s prevent maternal mortality from excessive bleeding”. The event was opened by H.E. Mr. Awol Arba, President of Afar Region. Representatives from the federal ministry of health, regional health bureau head (Dr. Ferej Rebissa), regional health bureau experts, different sector bureau officials, zonal and regional health office representatives, partners and community representatives attended the event. More than 300 participants have attended the event and it was joined with facility visit, blood donation program and final discussion with the FMOH and Regional Health bureau head and representatives to further strengthen leadership support for improving maternal health.
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Figure 10. Safe mother hood event celebration in Afar, Feb 2019.
Regional Youth forum:
The regional SRH forum was conducted at Logia town with regional and Woreda partners to create an enabling environment for youth through transformation plan. Amref Health Africa through A’ago project has taken part and provided technical support to integrate adolescent and youth issues with in the Woreda transformation plans.
Revitalization of women development army: The government of Ethiopia, Federal Ministry of Health has been implementing the health extension program for decades across all regions of Ethiopia. However, health extension workers program in the pastoralist area is not as strong as the one in the agrarian community. In response, the FMOH together with pastoralist regions has develop a pastoralist health extension strategy. Following which, the regional health bureau organized a regional level workshop to revitalize the women development army in pastoralist communities. A’ago project has provided technical and financial support in organizing the event, which was opened by the state minister, Her Excellency Dr. Liya Tadesse, and attended by the regional health bureau head, zonal and regional health office heads and partners.
3.2 Meaningful Youth Engagement on SRH 3.2.1 Youth Advisory Parliament
During the reporting period, the project planned to establish at least five youth advisory parliament at district level. So far, two districts, Argoba district and Awash town, have established youth advisory parliaments to engage youth at project implementation in their respective districts. The advisory parliament members support the project in social mobilization events and will promote SRH messages for adolescents and youths in their districts. The parliament is structured. Further expansion and establishments will be done in the rest of the districts.
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4. Monitoring, Evaluation and Learning
4.1 Surveys and Operational researches 4.1.1 Client Satisfaction Survey This survey has been conducted during the reporting period with major objective of assessing clients’ satisfaction and their experiences at various health service delivery points among public health centers and hospitals as well as private health facilities. During the survey, comprehensive SRH service-related structured questionnaire was completed with more than 450 clients excluding those. The survey finding will be used to further inform project support and advise facilities to address critical gaps. The finding will also be a benchmark from which change in terms of quality as a result of the various project interventions will be measured. Currently, data entry, cleaning and analysis is completed. The report will be finalized in the first quarter of the upcoming reporting period.
4.1.2 A’ago Midterm Evaluation:
Mid-term evaluation TOR and advertised to independently review the two years progress of the project in a structured manner is finalized. However, the project has faced difficulty to get the right consultant as well encountered security challenge to complete the review as per the original plan. The project is working hard to finalized the mid-term review will be in the first quarter of the third year.
4.1.3 Health facility Rating Triggerise has developed a health facility rating through the Tiko system which was communicated among partner. It is designed to provide insight to health facilities and health workers on client opinion and experience while getting SRH services in the facility. The data was collected using phone calls to randomly selected clients who have registered for Tiko system based on five predetermined questions, mainly focusing on whether the client likes how the health worker treated her, whether the provider explained the available service options, whether the provider explained the side effects, and if there were any complaints from the client. The summary of the results shows that: . 268 adolescent and young women have been called for feedback on their experience with the Tikosystem membership. . Out of the total, 183 respondents replied to how they heard about the Tiko system and; 40% answered through a Tiko Pro, 38% through a friend and 22% from clinic. . The majority of Rafikis (61.7%) joined the membership because of free health service they can get. The rest mentioned the opportunity to get discounted items and offerings. . The data shows communication is still an issue, out of the 85 people asked how well they are informed about the Tiko system, 53% stated the offers are not well explained. . The average rating of the service was 4.26 out of 5, which was 3.96 for Amibara Health Center, 4. 39 for Awash health center, and 4.4 for Mile health center. The findings were all communicated to health facilities and EngenderHealth program officers for their action. However, the call center has encountered one complaint from a client, whose mobile phone was picked by her husband. This challenged confidentiality and the team discussed among the consortium members and decided to suspend the survey.
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4.2 Technical backstopping 4.2.1 Periodic monitoring and follow up of interventions The fact that community interventions need close monitoring; the project team in collaboration with Woreda health offices have conducted quarterly supportive supervision and follow up activities in all intervention districts. During the visit, we have used checklists to assess progress and provide feedback for future improvements. As a result, 48 health posts, 12 schools and 23 HCs were covered by the supportive supervision and periodic monitoring activities. One of the major observations of the supportive supervision was the weak public health system at community, which restricted the implementation of the trainings provided to most of the health workers. Thus, the project team strengthened its follow up and additional efforts to increase community awareness and demand at this level.
4.2.2 Regular review meetings with public health facilities and community health workers As part of project monitoring, monthly and semiannually review meetings were planned to be implemented regularly. Review meetings for health facilities and community work were conducted separately by the different consortium partners, Amref and EngenderHealth. For Community level activities, Amref has organized a series of monthly and quarterly review meetings with partners. Monthly review meetings were conducted at district level and quarterly review was conducted at cluster level with district health offices and community health workers. At the end of every review meetings, action plans were developed and that has been serving as point of reference on performances tracking during subsequent review meetings.
For facility level activities, performance review was lead through EngenderHealth and conducted at quarterly level among health service providers, health facility heads and project consortium partners. Three successive reviews have been conducted mainly focusing on CC and CAC services. In each of the meeting, the team discussed on major achievements, challenges and put action plans to improve performance. The major concern raised in the early two review meetings was frequent commodity stock out. Following this feedback, EngenderHealth has discussed with the regional health bureau and the regional pharmaceutical supplies agency hub and identified that completing report and requisition form was a challenge from most health facilities. Finally, A’ago project supported IPLs and Logistics management information system (LMIS) orientation for all the health facilities supported by the project in partnership with the regional pharmaceutical supplies agency.
4.2.3 Joint supportive supervision and follow up visit Following the training programs delivered, it is expected that both in school and out of school youths, community-based activities and health facility interventions need to start operating actively. As every pace of the interventions need close follow up and support, joint supportive supervision has been conducted in collaboration with Woreda health offices, youth, women and children affairs and sport federations in all project impact areas. In the health facilities, regional health bureau experts and district health office experts participated in every review to understand the existing situation on FP and CAC services. The aim of the supervision was to understand project implementation gaps and provide required support for effective implementation of planned activities. Major findings during joint supportive supervision include; improvement of the motivation mechanism for health workers to expand services, strengthening community- based mentorship and supporting the functionality of health posts, strengthening women 22 development army and youth friendly services. These are in line with the project plans and continuous supports are being provided from the project; however, issues that need the administrative measures were shared to the respective bureaus.
4.3 Project Governance 4.3.1 Establishment of project Advisory committee A multidisciplinary project advisory committee was established from different sectors including the MOH, regional sector offices, Donor and project implementing partners. Before establishing the committee, draft memorandum of understanding (MOU) was prepared and the committee members discussed on it and provided their inputs. After the members have ratified the MOU; minute was prepared and signed by all members. RHB head is selected to chair the committee while EH country representative will serve as a secretary. The committee will meet every six months to play their role as per their scope of work clearly stated in the MOU. 4.3.2 Steering Committee Meeting with Project Team The A’ago project steering committee conducts regular meetings every quarter. Major project progresses, challenges encountered and measures to be taken are discussed and actions taken to ensure smooth running of the project. The steering committee also made field visit and attended field level monthly reviews. Major issues addressed through the project steering committee includes both programmatic and administrative. Programmatic actions taken include actions to strengthening community referrals, integration of Triggerise interventions with Amref and EngenderHealth program interventions, and guidance on documenting and taking corrective actions on the Fiema structure. Administratively, the steering committee provided direction for a unified project management matrix.
VIII. Lessons Learnt and Success factors Implementation of the A’ago project was initiated two years back in September 2017. Over the past two years, the project has registered promising successes in expanding access to quality adolescent and youth health services. The following points summarize the major successes and contributing factors:
1. Progressively improving SRH service uptake: Because of the deep rooted sociocultural barriers and weak health system, most partners working in the Afar region have been frustrated and refrained from supporting SRH services particularly contraceptive and abortion care service. Building on experience in other parts of the country, EngenderHealth and its consortium partners designed region specific and tailored project interventions supported with innovations. The project has implemented integrated demand, supply and advocacy intervention that enabled the regional health bureau to improve access to CC and CAC services. For example, at baseline, IUCD uptake was on average five cases per facility per year, where most facilities even do not provide the method at all. Now, for A’ago supported facilities, this is a monthly average, 5 clients served per month per facility. On the other hand, access to safe abortion care was nearly absent before the project and now all facilities provide the service. On the other hand, with in short period of initiating BEmONC services, the project has witnessed a significant improvement in uptake of institutional delivery. For example, in Boloyta health post, confirmed referral for delivery service has increased from three per month to 12 per month. The main success factor for this include provision of competency based training, close follow up support tailored to
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individual health worker need and strong clinical mentoring. Strengthening of outreach services with the support of Philips backpack at the community level and referral linkages has also contributed to the success.
2. Young people and community leaders has started challenging harmful traditional practices and cultural taboos such as abduction. The success factor for this is the strong awareness creation interventions carried out in-school, out of school and at the community level. Social mobilization and community leader’s engagement initiatives that promote the health and rights of adolescent girls and young women particular among influential community leaders also contributed to the change in community perception. However, challenges also remain huge. For example, female genital cutting (FGC) is highly prevalent in the project area; especially the “Suna” type is considered a religious requirement. Despite efforts to reduce FGC by multiple partners in the region, FGC is commonly practiced and resistance from the community to stop the practice is immense. Currently, we have noted that religious leaders have started their own initiative in opposing and saying no to FGC, after being convinced on its health implications to their daughters, wives and families in general. The main success factor for this change is believed to be high-level dialogue sessions and trainings conducted with gatekeeper’s particularly religious leaders and clan leaders.
3. Traditional birth attendants (TBAs) can be trained and assume a constructive role as women development armies: TBAs have been playing significant role in the Afar community accompanying home-based delivery. Evidences suggest that these practices delay decision-making and referral to health facilities, which in turn will lead to complications related to delivery. They also have been rewarded in kind (like goats and camels) as compensation for attending the home delivery. However, among, A’ago project sites, many of the TBAs are voluntarily shifting their role to being a part of the Women development army and are teaching their community the importance of institutional delivery and referring cases to health facilities. The main success factor for this task shifting is community dialogue activities and awareness creation events carried out at community level.
4. Strong support for the project among communities and public leaders: Communities and public governance bodies have extended support and appreciation for the comprehensive SRH services the project is implementing in the region. To mention, the regional health bureau has provided the project a regional office in their compound, and they support the project team with vehicles when the team demands. The main reason behind is the different expertise that the project has brought through its consortium partners, the comprehensiveness of the services it supports, its focus on strengthening the public system with new and pastoral community friendly initiatives, like the Philips community life center (backpack) supplies.
IX. Challenges encountered and measures taken
Working in Afar region of Ethiopia is both an opportunity and a challenge. The public and private health system in the region is relatively weak, which requires extensive work, and it is an opportunity to reach the needy community. Especially, adolescents and youths in the region are highly underserved for various reasons, mainly cultural values that have a deep-rooted gender and age discriminations among boys and girls, women and men and young people and the
24 elderly. At the same time, reaching the pastoralist community in the region is a challenge from various perspectives. The geographical set up is very dry, hot and the population is sparsely populated. Major infrastructures like road, communication and social institutions are underdeveloped. Most of the pastoral communities also are mobile who moves with their cattle’s and families in search of water, access to grazing land and avoid clan-based conflicts.
Accordingly, A’ago project is not immune to face those challenges while expanding SRH services. However, the specific challenges the project faced during the reporting period include
Security Challenges: The community structure is based on clan arrangements, which encounters frequent conflicts. Especially, in the past two to three years, the political system in the country has exacerbated the local security situation in Afar. The project team encounters frequent roadblocks, clan conflicts and mass moves, which interfere with our project implementation. The project lead, EnegnederHelth has established a security and safety plan to track and advise the project team on important security measures. EnegnederHelth also advised project consortium to establish similar mechanism and provided field level support, when needed. Emergency: The region frequently encounters droughts, which leads to shortage of access to potable water supply, increased incidence of water borne and water washed diseases, flooding which mainly comes from Awash River following rainy season in the highland parts of Ethiopia, and undernutrition. Three districts mainly Logia-Semera, Amibara and Gelealo were affected in the report period. The project monitors emergency situation regularly to inform project implementation. Emergency responses were further coordinated with the regional response and the project supported in kind and technically. However, a systematic approach and budget allocation is very important for future interventions. Weak community structure: A’ago project has planned to support and strengthen the existing community structure. However, in most of the project sites, the existing system does not function and it was a big challenge to motivate and bring those structures to action. In some of the Kebeles, the structures like women development army were not totally available. In this context, in collaboration with the local administration, the project was forced to establish such structure from the scratch. Similarly, the Fiema groups that was considered to reach the out of school adolescent and youth were found to be loosely structured, and the majority of them are males. This affects the gender balance in reaching adolescent and youth girls. The HEWs structure is also weakk and insufficient to provide FP services and referral for CAC, and the attention of the leadership is very important. The A’ago project team has also noted the presence of weak health center and health post linkage. The project has continued to learn and adopt project interventions and tailor project support to the regional context. Frequent Commodity stock out: Most facilities in the region encounter frequent contraceptive commodity stock outs, especially in the first semi-annual period of the year. This required the project to do additional investment in training and mentoring the pharmacy technicians at a facility level to follow up with providers and submit timely commodity report and request for EPSA regional hub. The project has also supported coordination among health facilities and EPSA hubs to ensure sustain supply of CC and CAC commodities.
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High staff turnover from facilities: The project has encountered high turnover of trained health workers with in short period after training. In the reporting period, among 158 trained service providers on CC, CAC and BEmoNC, 22(14%) of them had left the facility. The project has reported the challenge to the regional health bureau and in the mean time provided a gap filling training to avoid service interruption. Delay in purchase of medical equipment's and supplies: While the project did timely needs assessment and procurement bids, in the past year, due to foreign currency shortage, most local vendors were not having sufficient stock of medical equipment and consumable supplies. The vendors provide longer lead time and in most instances fail to deliver orders on time, impacting the project capacity to deliver required medical equipment and supplies to the project sites. EngenderHealth is examining possibility of direct oversea purchase through it’s headquarter.
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X. Annexes:
Annex 1: A'ago project year 2 annual plan and achievement summary, July 2018 – June 2019
Total project period Annual Remarks Unit of (TPP)
List of planned activities by objective .
. Measurement
% %
Plan
Ach
Plan Ach Obj. 1: To increase demand for SRHR information and service among young people and their communities 1.1. SRHR education for out-of-school adolescent and youth TOT training for health workers and A’ago project staff on Adolescence and Youth Health Trainees 20 20 100 20 20 100 Engage Fiema/youth groups on SRH (male and female) at a Current, 9 groups are active and Kebele level Youth Group 20 18 95 60 38 63 the rest remain difficult to engage Fiema groups training on WSWM-Meharebie version/ Life Extra group trained as refresher skill Training Person 150 214 143 180 214 119 training Support Fiema peer dialogue sessions on SRH (Coffee Dialogue/ Traditional Fiema groups are Ceremony) sessions 180 125 69 480 239 50 difficult to track and work with Married and pregnant adolescents couple group conversation Pastoral motilities coupled with on SRH (male and female) Conversation security issues pose difficult to session 113 26 23 1104 26 2.4 access married adolescents. HEWs and Fema facilitators review meeting and refresher training District 12 9 75 36 18 50 1.2. SRHR education for in-school adolescent and youth School facilitators training to implement WSWM in Schools School directors included for Person 63 95 150 105 95 90 follow up support School sensitization on Comprehensive SRH services School communities motivated to Person 130 224 172 130 224 172 attend sensitization events Support schools to establish SRH clubs/WSWM centre School 34 30 88 34 30 88 Number of adolescent and youth (students) who completed 9 schools lately joined the (ever received) comprehensive sexuality education program. Number of students Person 560 516 92 2100 516 24 involved will improve next year
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Total project period Annual Remarks Unit of (TPP)
List of planned activities by objective .
. Measurement
% %
Plan
Ach
Plan Ach
Biannual review of in school interventions at a cluster level Person 145 115 79 435 115 26 1.3. Community based SBCC interventions Health communication strategy development Document 1 1 100 1 1 100 Train HEWs and Feima representatives on community engagement for SRH Person 360 237 66 360 237 66 Provision of printing materials to WDAs (in thousands) FHG 10 8 80 16 8 50 FHG: Family Health Guide Support the development of radio programs months/ episodes 0 0 0 0 0 0 36 episodes under development Under achieved due to security Conducting market place campaigns and social events using challenge and staff turnover. AY themselves including furnishing one vehicle Event 18 6 33 54 6 11 Efforts under way to scale up #of review Annual review meeting to strengthen community activities /District 9 8 89 27 8 30 PHCU (primary health care unit) review meeting PHCU 23 13 57 23 13 57 focused to strengthen the PHCU
1.4 Initiate and scale up mHealth solutions to reward behaviour Beneficiaries who Establish motivation and Establish motivation and reward mechanisms 2874 5739 199 14153 5739 40.5 uptake services. reward mechanisms. Call centre Develop call centre questionnaire and pilot in Afar. interviews 300 268 89 3,600 268 7 conducted Objective 2: To increase access to and quality sexual and reproductive health (SHR) services, including CEFM and GBV counselling 2.1. Health workers capacity building on essential SRH services Support public health facilities to provide comprehensive FP services Facility 20 25 125 33 25 75.8 Support public health facilities to provide comprehensive New expansion target included abortion care services Facility 20 25 125 129 25 19.4 in the total plan Support Health Facilities to provide BEmONC services Facility 10 12 120 15 12 80 Support Private health facilities to provide CC/CAC services Facility 10 11 110 34 11 32.3 Training of health workers on comprehensive contraception, comprehensive abortion care, AYH and BEmONC services Person 450 555 123 774 555 71.7
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Total project period Annual Remarks Unit of (TPP)
List of planned activities by objective .
. Measurement
% %
Plan
Ach
Plan Ach
Training of Health Extension workers on Comprehensive FP HEWs are not eligible for the service Person 125 43 34 250 43 17.2 training HEWs and HWs training on Philips back packs Person 100 98 98 300 98 32 Will continue next year Procurement facilitated but not Support health data management system (DHIS an d CHIS) HFs 12 0 0 23 0 0 distributed yet 2.2. Quality improvement for SRH Conduct facility orientation persons 188 322 171 300 322 107
Individual providers follow up and support persons 120 115 95.8 774 115 14.5 Clinical mentoring and catching visit 2 1 50 6 1 16.7 2.3. Strengthen relevant SRH structures (infrastructure and medical supply at service delivery points) Construction/renovation of HCs to improve health facility All year 2 constructions are readiness for AYH services HCs 6 6 100 12 6 50 finalized. Procurement is on Construct maternity waiting areas HCs 4 4 100 12 4 33 process for remaining works. Distribution of supplies and equipment’s, including the back Phase based approach chosen due packs Back packs 126 41 33 126 41 33 to the capacity of HFs 2.4 Improve SRHR service uptakes Pills person 117 1575 135 11356 1575 13.9 Regional baseline was low Injectable person 1942 4259 219 15487 4259 27.5 Regional baseline was low IUD person 60 83 138 1131 83 7.3 Regional baseline was low Implants person 292 1249 428 4921 1249 25.4 Regional baseline was low ANC1+ person 3680 1243 34 20610 1243 6 Service initiated in May, 2019 ANC4+ person 1750 412 24 10630 412 4 Service initiated in May, 2019 Skilled Delivery person 1110 460 41 6016 460 8 Service initiated in May, 2019 Safe Abortion Care person 150 277 185 8863 277 19 Regional baseline was low STIs person 168 748 445 1079 748 69 Quality service PNC person 718 1201 167 3213 1201 37 Quality service Obj 3: Improve the enabling environment for youth and adolescent including girls and young women to exercise their SRH entitlements 3.1. Strengthening supportive socio cultural community structure It needs target adjustment, Establish and train WDA members No 300 260 87 achieved project targets
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Total project period Annual Remarks Unit of (TPP)
List of planned activities by objective .
. Measurement
% %
Plan
Ach
Plan Ach
Conduct training and mobilization for gatekeepers Person 40 132 330 130 132 102 3.2 Empowering adolescent and youth to demand and exercise and influence their SRHR Security challenges delayed this Establish project advisory group from youth Group 9 2 22 9 2 22 activity Youth group support in social Support and establish youth groups with innovation fund No 9 1 11 9 1 11 mobilization 3.3. Enforcement of SRH laws Support regional Forums event 2 3 150 8 3 37.5 4. Monitoring and Evaluation Conduct different programs feasibility assessment (back packs,
LEAP) No 1 1 100 2 2 100 Joint supportive supervision (With RHB) No of JSS 1 1 100 4 1 25 Case story documentation and sharing No 2 3 150 10 3 30 Provide DHIS2 training No 10 17 170 10 17 170 Conducting quarterly meetings No 4 3 75 12 3 25
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Annex 2: Contraception and CAC services provided by age and Sex category in A’ago supported health facilities, July 2019- June 2019
Female (age) Male S.No Service Type Under 20 & Unknown All Total 20 above Age Age I Family Planning 1 # Clienets Provided FP Counselling Only 873 3,575 0 151 4,599 2 # clients who received condoms 185 1,041 0 178 1,404 3 # of condoms provided 1,069 6,973 4 1,080 9,126 4 # clients who received pills 257 1317 1 0 1575 5 # pills (cycles) provided 482 2467 0 NA 2949 6 # of 3-month injectable provided 617 3,622 20 NA 4,259 7 # clients who received IUDs - Copper T (insertions) 15 68 0 NA 83 8 # IUD removals 0 20 0 NA 20 9 # clients receiving a Jadelle implant (insertions) 11 65 0 NA 76 10 # clients receiving an Implanon implant (insertions) 110 444 0 NA 554 11 # clients receiving a Sino-Implant (insertions) 8 48 0 NA 56 12 # clients receiving a Nexplanon implant (insertions) 58 505 0 NA 563 13 # implant removals 26 230 0 NA 256 14 # clients who received female sterilization (ML/LA/BTL) 0 11 0 NA 11 Total Contraceptive services offered 3,711 20,386 25 1,409 25,531
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II Comprehensive Abortion Care 1 Total # safe abortion/PAC clients served 95 449 10 NA 554 2 Post abortion FP/PAFP # safe Abortion/PAC clients who received FP counseling 12 67 0 NA 79 only (did not receive a method after counselling) # safe abortion/PAC clients who received condoms 0 2 0 NA 2 # safe abortion/PAC clients who received pills 5 21 0 NA 26 # pills (cycles) provided to safe abortion/PAC clients 24 33 0 NA 57 # of injectables provided to safe abortion/PAC clients 21 103 0 NA 124 # safe abortion/PAC clients who received IUDs - Copper 17 42 0 NA 59 T (insertion) # safe abortion/PAC clients receiving an implant 19 101 0 NA 120 (insertions) Total # clients receiving post abortion FP/PAFP 62 269 NA NA 331
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