STRENGTHENING

ETHIOPIA‘S URBAN HEALTH PROGRAM

Annual Report 2017

STRENGTHENING ETHIOPIA’S URBAN HEALTH PROGRAM

ANNUAL REPORT

OCTOBER 2016 – SEPTEMBER 2017

Cooperative Agreement No.AID-663-A-13-00002

SUBMITTED TO: USAID/Ethiopia

PREPARED BY: John Snow, Inc. (JSI)

CONTACT INFO FOR THIS REPORT: HIBRET ALEMU TILAHUN, PHD JSI/SEUHP CHIEF OF PARTY EMAIL: [email protected] TEL: +251114700402/45

DISCLAIMER: This document is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of JSI Research & Training Institute, Inc. (JSI) and do not necessarily reflect the views of USAID or the United States Government.

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ACRONYMS AND ABBREVIATIONS

AAU/SPH Addis Ababa University School of Public Health AACARHB Addis Ababa City Administration Regional Health Bureau ANC Antenatal care ARM Annual review meeting ART antiretroviral therapy AWD acute watery diarrhea (cholera) AYRH adolescent youth reproductive health BCC behavior change communication C/THO city/town health office CHIS community health information system DQA data quality assessment EDA Emmanuel Development Association EPHA Ethiopian Public Health Association (EPHA) EPI Expanded Program on Immunization Extension Program FANC Focused antenatal care FMOH Federal Ministry of Health FHC family health card FHT Family health team FP family planning FY fiscal year HBHTC home-based HIV testing and counseling HC h ealth center HDA health development army HEW health extension worker HH household HIV human immunodeficiency virus HMIS health management information system HRM human resource management HSPH Harvard School of Public Health HSTP health sector transformation plan HTC HIV testing and counseling ICU Intensive care unit IEC information, education, and communication IR intermediate result IRT integrated refresher training ISS integrated supportive supervision IUSHS Integrated Urban Sanitation and Hygiene Strategy JSI John Snow, Inc. JSS joint supportive supervision KMC kangaroo mother care LBW low birth weight LMG leadership, management and governance LQAS Lot Quality Assurance System

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MARPs most at risk populations M&E monitoring and evaluation MNCH maternal, newborn, and child health NCD non-communicable disease OCA organizational capacity assessment OPD outpatient department PEPFAR President's Emergency Plan for AIDS Relief PHC primary health care PLHIV people living with HIV PMP performance monitoring plan PMTCT prevention of mother-to-child transmission (of HIV) PNC postnatal care QI quality improvement QII quality improvement initiative RDT rapid diagnostic test RH reproductive health RHB regional health bureau SBCC social behavior change communication SEUHP Strengthening Ethiopia‘s Urban Health Program SNNPR Southern Nation and Nationalities People Region SDRT service data recording tool TB tuberculosis THO town health office TOT training of trainer TTG think tank group TWG technical working group UHEP urban health extension program UHE-p urban health extension professional USAID United States Agency for International Development WASH water, sanitation, and hygiene

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TABLE OF CONTENTS

ACRONYMS AND ABBREVIATIONS ...... - 3 -

TABLE OF CONTENTS ...... - 5 -

I. REPORTING PERIOD ...... - 6 -

II. PUBLICATIONS/REPORTS ...... - 6 -

III. TECHNICAL ASSISTANCE ...... - 7 -

IV.TRAVEL AND VISITS ...... - 8 -

V. ACTIVITY ...... - 9 -

PART 1: ACCOMPLISHMENTS AND SUCCESS DURING THE REPORTING YEAR ...... - 13 -

PART 1.1 IMPROVED QUALITY OF COMMUNITY-LEVEL URBAN HEALTH SERVICES ...... - 14 -

PART 1.2: INCREASE DEMAND FOR FACILITY-LEVEL URBAN HEALTH SERVICES (IR 2) ...... - 34 -

PART 1.3: STRENGTHEN REGIONAL PLATFORMS FOR IMPROVED IMPLEMENTATION OF THE NATIONAL URBAN HEALTH STRATEGY (IR 3) ...... - 44 -

PART 1.4: IMPROVE SECTORAL CONVERGENCE FOR URBAN SANITATION AND WASTE MANAGEMENT (IR 4) ...... - 66 -

PART 1.5: OTHER KEY ACTIVITIES ...... - 87 -

PART 1.6: SEUHP COMMUNICATION AND DOCUMENTATION-RELATED KEY ACTIVITIES AND ACCOMPLISHMENTS ...... - 92 -

PART 1.7: OPERATIONS AND FINANCE: KEY ACTIVITIES AND ACCOMPLISHMENTS ...... - 95 -

PART 1.8: DATA QUALITY ISSUES DURING THE REPORTING PERIOD ...... - 99 -

PART 1.9: CHALLENGES AND PLANS TO OVERCOME THEM DURING THE REPORTING PERIOD...... - 102 -

PART 1.10 MAJOR ACTIVITIES PLANNED IN THE NEXT REPORTING PERIOD ...... - 103 -

ANNEXURE ...... - 105 -

Annex 1a: Success story-1...... - 105 -

Annex 1b: Best practice-2 ...... - 107 -

Annex 2: Summary of Emergency WASH construction Activities: Progress in FY17 ...... - 109 -

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I. REPORTING PERIOD From To

October 1, 2016 September 30, 2017

II. PUBLICATIONS/REPORTS

Did your organization support the production of publications, reports, guidelines, or assessments during the reporting period?

No/Not Applicable

Yes X If yes, please list below:

Publications/Reports/Assessments/Curriculums

Title Author Date

Strengthening Ethiopia‘s Urban Health Program (SEUHP): DECEMBER JSI/SEUHP Annual Report Summary 2016

Urban Health Extension Program Integrated Refresher Training Modules (Six Modules on SBCC, RMNCH, Wash, FMOH FEB. 2017 Major Communicable Diseases, NCD, And Basic First Aid- Facilitator‘s Guide And Participant‘s Manual for Each)

Revised UHEP Implementation Manual For Oromia (In OROMIA RHB FEB. 2017 Afaan Oromo)

Urban Primary Health Care (PHC) Reform in Addis Ababa: AAU/SPH JAN. 2017 Expert Appraisal (Technical Report)

Social Determinants Of Urban Health In Ethiopia: Call for AAU/SPH JAN. 2017 Equity (Policy Brief)

Integrated Urban Sanitation and Hygiene Strategy FMOH APRIL 2017

Joint Committee on Implementing National Hygiene and Environmental Health & Integrated Urban Sanitation and FMOH APRIL 2017 Hygiene Strategy

Demographic and Societal Patterns of Urban Populations in JSI/SEUHP/FMOH 2017 Ethiopia

Key Findings of the Mapping Exercise on the Existing Public JSI/SEUHP/FMOH 2017 Latrines In 28 SEUHP-Targeted/Cities/Towns in Ethiopia

Integrated Urban Sanitation And Hygiene Strategy – IUSHS: JSI/SEUHP/FMOH May 2017 Summary of the Strategy –Extracted from the Main Strategy

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Document

Ethiopia‘s Urban Productive Safety Net Project JSI/SEUHP/FMOH March 2017

Ethiopia‘s Primary Health Care Reform: Practice, Lessons, JSI/SEUHP/FMOH March 2017 and Recommendations

Ethiopia‘s Primary Health Care System in Urban Areas JSI/SEUHP/FMOH March 2017

Ethiopia‘s Urban Health Extension Program JSI/SEUHP/FMOH March 2017

Strengthening Ethiopia‘s Urban Health Program (SEUHP) JSI/SEUHP/FMOH March 2017 annual report summary

Ethiopia‘s 1st Annual National Conference On Urban Health: Conference Proceedings, Hilton Hotel Addis Ababa, JSI/SEUHP/FMOH May 2017 Ethiopia, April 3-4, 2017

III. TECHNICAL ASSISTANCE Did your organization utilize short-term technical assistance during the reporting period?

No/Not Applicable

Yes X Please list below:

Consultants/TDYers

Name Arrival Departure Organization Type of Technical Assistance Provided

Angela Murray September November JSI To provide technical support on WASH. 2016 2016

Maceda Alemu March 14 2017 March 16 JSI To provide administrative support by 2017 coordinating with other business trip.

Christele Joseph- March 13 2017 March 17 JSI To provide operations and finance support pressat 2017 by coordinating with other business trip.

Shaina Bauman Aug. 16-2017 Sep. 08,2017 JSI To provide support for communication and documentation work

Matthew Zinck Aug 16, 2017 Sep. 04,2017 JSI To attend the FY 2018 work plan activity and orient himself with the Field office operations

Anne Austin Aug 26, 2017 Sep. 04,2017 JSI To participate the FY 2018 work plan activity and to support the M & E of the project

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IV. TRAVEL AND VISITS Did your organization support international travel during the reporting period?

No/Not Applicable

Yes X Please list below:

International Travel (All international travel to conference, workshops, trainings, HQ, or meetings).

Name Destination Departure Arrival Host Purpose of the travel from Organization Ethiopia Hibret Vancouver, Nov. 11 Nov. 21 JSI/SEUHP To attend the Global Symposium on Alemu Canada 2016 2016 Health Systems Research

Dr USA April 5, April 6, Consortium Present a scientific paper at the CUGH Mebratu (Washington 2017 2017 of Universities Conference Bejiga DC and for Global Work visit at JSI Boston Office Boston Health, JSI Home Office Yibeltal USA April 5, April 6, Consortium Present a scientific paper at the CUGH Tebekaw (Washington 2017 2017 of Universities Conference (PhD) DC and for Global Work visit at JSI Boston Office Boston) Health, JSI Home Office Hibret USA April 8, April 16, JSI Home Internal SEUHP project management Alemu (Washington 2017 2017 Office meeting. (PhD) DC and Boston) Hibret Thailand May 9, 2017 May 14, Thai Health Preparation for the structured learning Alemu 2017 Commission visit on Primary Health Care (PhD) Birhanu Coimbra, Sept. 24, Sept 30, JSI/SEUHP Present a scientific paper at the 14th Genet Portugal 2017 2017 International Conference for Urban Health Asnake Coimbra, Sept. 24, Sept 30, JSI/SEUHP Attend the 14th International Kassahun Portugal 2017 2017 Conference for Urban Health

Getu Coimbra, Sept. 24, Sept 30, AA RHB Attend the 14th International Bisa Portugal 2017 2017 Conference for Urban Health

Anwar Coimbra, Sept. 24, Sept 30, AA RHB Attend the 14th International Nuru Portugal 2017 2017 Conference for Urban Health

Ruth Washington July 17, July 29, JSI/SEUHP To attend the annual conference inside W/tensay DC and 2017 2017 NGO and to discuss financial and Boston administrative issues with JSI home office

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V. ACTIVITY Program Area Activity ID Activity Title ( Please write the title of the activity) (Tick all that apply)

X01-PMTCT AID-663-A-13-00002 JSI/SEUHP

02-HVAB

03-HVOP

04-HMBL

05-HMIN

07-CIRC

X08-HBHC AID-663-A-13-00002 JSI/SEUHP

X09-HTXS AID-663-A-13-00002 JSI/SEUHP

10-HVTB

11-HKID

12-HVCT

13-PDTX

14-PDCS

15-HTXD

16-HLAB

17-HVSI

X18-OHSS AID-663-A-13-00002 JSI/SEUHP

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SUMMARY MAJOR ACCOMPLISHMENTS IN THE

REPORTING PERIOD

The followings are major achievements in of FY2017 from October 1, 2016 to September 30, 2017:

. Strengthening Ethiopia‘s Urban Health Program‘s (SEUHP) coverage reached the target of 49 towns with the addition of two new towns from SNNPR. . SEUHP supported printing of the urban IRT modules: 3,000 copies of the Facilitator‘s Guide and 12,000 copies of the Participant‘s Manual for the first three modules (SBCC, RMNCH, and WASH—1,000 Facilitator‘s Guides and 4,000 Participant‘s Manuals each). . SEUHP in collaboration with the Federal Ministry of Health (FMOH) organized master training of trainers (TOT) on integrated in-service refresher training on urban health extension professionals (UHE-ps) for 28 government health experts and SEUHP staff members. About 287 individuals received regional level TOTs from Amhara (72), Tigray (26), Oromia (86), SNNP (46), Dire Dawa (12), Harari (11) and Addis Ababa (34) regions. . SEUHP provided technical support on the cascading of the three IRT modules i.e., Social and Behavior Change Communication (SBCC), Reproductive, Maternal, Newborn, and Child Health (RMNCH), and Water Sanitation and Hygiene (WASH) for a total of 2,299 UHE-Ps, their supervisors and other professionals. . Regional level contextualization, translation into local languages and launch of the revised urban health extension program implementation manual was accomplished in Oromia and Tigray regions. . To address the challenges related to a lack of supplies, SEUHP purchased and distributed more than 2,300 nursing-bags, 2,300 thermometers, and 520 blood pressure measuring apparatuses with stethoscopes to UHE-ps in the seven SEUHP-supported regions. . Refresher training sessions on quality improvement were organized for 898 quality improvement team members and basic quality improvement training for 146 trainees (98 females) to establish ten new quality improvement teams. . Preparation of national guide for referrals made by (UHE-ps) is underway in collaboration with FMOH/ Primary Health Care and Health Extension Program Directorate through establishing urban referral taskforce. . UHE-ps referred 55,736 (14,994) individuals (77.6% females) for health and social services using referral slips accounting for 85.7% and 95.6% of the annual and fourth quarter targets respectively. . Through the support of SEUHP, UHE-ps provided HIV testing and counseling (HTC) services to 21,834 individuals, accounting for about 240.7% of SEUHP‘s FY17 annual target. Of the total tested by UHE-ps, number of HIV positive cases was 374 resulting in a yield of 1.71% (2.03% for females and 1.17% for males). Besides, the highest HIV positivity was recorded among the widowed (3.75%) followed by the divorced (3.28%), and sex workers (3.24%). . Health services including Health education on hygiene and sanitation, immunization, bed net distribution, De-worming, Vitamin A supplementation, nutrition screening to mothers and

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children, and care and support for chronic diseases, family planning, ANC follow up, and post- natal care services were provided for 62 families of homeless people residing at streets and church vicinities in Bahir Dar, Finote Selam, and Gondar towns. . With technical support from SEUHP, UHE-ps provided direct services (excluding health education) to 641,936 individuals accounting for 111% of the annual target. . In line with FMOH‘s plan to scale up the Primary Health Care (PHC) reform initiative SEUHP supported its expansion to 20 health centers in Addis Ababa and in one regional town in Amhara, Tigray, Or Omiya, Southern Nations Nationalities and Peoples (SNNP), Dire Dawa and Harari regions. During the reporting period, SEUHP supported the training of 873 Family Health Team (FHT) members (378 female) in SEUHP supported regions. . About 216,966 job aids, education materials, leaflets, brochures, and other support materials were distributed to UHE-ps and families. . Leadership, Management and Governance (LMG) training was provided to 431 government health officials in Addis Ababa, Oromia, Amhara, Tigray, and SNNP regions. . As a member of the national technical working group (TWG) for urban community health information system (CHIS), SEUHP provided substantial technical and financial support in the finalization of the CHIS guideline, tools, and training manual, validation of the ECHIS platform and has been playing elemental role in the pilot-testing (training, procurement of community folders, printing and distribution of community folder and the CHIS formats), and conducting supportive supervision and on-site coaching of CHIS in Addis Ababa, Oromia and SNNP regions. . SEUHP has introduced electronic data collection system for routine supportive supervision, data quality assessment and research. The electronic data collection approach will facilitate timely submission of data, resource efficiency (time and avoiding data entry), data quality, timely decision-making, etc. . SEUHP team conducted internal DQA for all five SEUHP supported regions (Amhara, Oromia, Tigray, SNNPR, Harari) and two City Administrations (Addis Ababa and Dire Dawa). SEUHP regional teams have been conducting regular data quality checks during data collection and supportive supervision visits to UHE- ps and their supervisors. . The first National Urban Health Conference (NUHC) was held from April 3-4, 2017 in Addis Ababa at the Hilton Hotel under the theme of Ethiopia’s Urbanization and Its Implication on Health: Acting Now to Save the Future. More than 300 participants including mayors, policymakers, heads of Regional Health Bureaus, town health officials, service providers, donors and development partners, academics, agencies, private sector, civil society organizations, professional associations and others attended the two-day conference. . As part of the partnership with Addis Ababa University/School of Public Health (AAU/SPH); SEUHP provided technical support in the finalization of data collection, field level facilitation during data collection and review of the data entry templates for the two studies: (1) mapping the risk and vulnerability of urban residents in relation to health and health related factors; and (2) assessing the quality of UHEP service delivery with a focus on UHE-ps‘ adherence and competency in line with the revised UHEP implementation manual. Currently, SEUHP has received draft reports for the two studies. Additionally, SEUHP partnered with researchers from AAU/SPH to conduct an appraisal assessment of the PHC reform initiative.

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. SEUHP organized training on monitoring and evaluation for staff members of Emanuel Development Association (EDA) in Amhara and Afar Regions, and supported the revision of EDA‘s Human Resource Manual. . SEUHP organized training to private Sanitation and Waste Management service providers, WASH TWG members, and school WASH club members. . Financially viable public latrine management model is developed and public-private partnership situational assessment conducted. . Construction and/or renovation of sanitation and hygiene facilities undertook in five towns; Adigrat and Alamata towns in Tigray Region and Sekota, Kombolcha and Kemessie towns in Amhara Region. . In relation to improving sectoral convergence for urban sanitation and waste management, SEUHP supported the establishment of WASH platforms (forum for multi-sectoral WASH actors); supplied low-cost sanitation products, and provided technical and logistics support for the national handwashing campaigns; and supported WASH movements. . Model WASH demonstration sites were established at schools and SEUHP organized national level experience sharing visits to these sites. . SEUHO provided support on emergency WASH interventions; organized review meetings; organized trainings on water quality management; and conducted supervisory visits to Emergency-WASH sites.

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PART 1: ACCOMPLISHMENTS AND SUCCESS DURING THE REPORTING YEAR

Strengthening Ethiopia‘s Urban Health Program (SEUHP) aims to improve the health status of the urban population in Ethiopia by reducing HIV and tuberculosis (TB)-related and maternal, newborn, and child mortality, and the incidence of communicable and non-communicable diseases (NCDs). SEUHP works to strengthen the Urban Health in Ethiopia Project (UHEP) by improving the quality, use, and management of community-level urban health and related services. SEUHP supports the health system by training urban health extension professionals (UHE-ps) and their supervisors; mentoring and coaching UHE-ps; establishing and training quality improvement teams at the health centers (HCs); and developing guidelines training modules and establishing a monitoring and evaluation (M&E) system as well as supporting multi-sectoral engagement in sanitation and hygiene areas. SEUHP has been working in five regional states (Amhara, SNNP, Or Omiya, Tigray, and Harari) and two city administrations (Addis Ababa and Dire Dawa) covering 49 towns/cities. There are 181 HCs and 2,287 UHE-ps in these targeted cities/towns.

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PART 1.1 IMPROVED QUALITY OF COMMUNITY-LEVEL URBAN HEALTH SERVICES

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Sub IR1.1: Improve knowledge, skills, and motivation of UHE-ps

1.1.1 Supported FMOH in the development, printing and distribution of IRT facilitators and participant manuals

The FMOH and SEUHP developed the competency-based in-service Integrated Refresher Training (IRT) modules based on the identified training needs of the UHE-ps and according to the required standards of practices delineated in the UHEP implementation manual. The training aims to optimize the competency of the UHE-ps in three crucial domains (attitude, skill, and knowledge) and, as a result, to improve their ability to provide high-quality services to their clients.

To facilitate the training of UHE-ps, SEUHP developed, printed, and distributed six IRT modules: Social and Behavior Change Communication (SBCC), Non-Communicable Diseases (NCDs); Water, Sanitation, and Hygiene (WASH); Major Communicable Diseases (MCDs); Reproductive Maternal, Newborn, and Child Health (RMNCH); and Basic First Aid.

In FY17, SEUHP supported the printing and distribution of 19,500 copies (including both facilitator‘s guide and participant‘s manual) of the first three IRT modules (SBCC, RMNCH and WASH) to Amhara, Addis Ababa, Dire Dawa, Harari, Oromia, SNNP, and Tigray regions.

Picture1: UIRT modules (SBCC, RMNCH and WASH)

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1.1.2 Organized IRT for UHE-ps

In FY17, the FMOH decided provide standardized, in-service training using the IRT modules to its frontline health workers as one of its key initiatives. In response, SEUHP has been providing support throughout the preparation, development, and delivery of competency-based IRT to improve UHE-ps‘ capacity to provide high-quality services to their clients. In this reporting period, SEUHP collaborated with the FMOH to organize a master TOT on competency-based training approaches and facilitation skills for 28 participants (21 from government and seven from SEUHP; 22 males and six females) from November 23–30, 2016 in Adama. The trainees were from nine regional health bureaus (RHBs) (Afar, Amhara, Benishangul Gumuz, Gambella, Harari, Oromia, SNPP, and Somali) and two city administrations (Addis Ababa and Dire Dawa). The training covered six modules: first aid; major communicable diseases; non-communicable diseases; RMNCH; SBCC; and (WASH).

Subsequently, regional level TOTs were organized in all seven regions supported by SEUHP. A total of 287 trainers were trained in; Amhara (72), Tigray (26), Oromia (86), SNNP (46), Dire Dawa (12), Harari (11) and Addis Ababa (34) regions. Of the trainers trained in the second quarter, 42 (17%) were females. The trainers were selected from regional health bureaus, zonal health offices, town health offices, health centers, and academic institutions. In the second half of FY 17, all SEUHP supported regions cascaded the first phase IRT which includes the SBCC, RMNCH, and WASH three modules. A total of 2,299 UHE-Ps participants, including their supervisors and other professionals attended the 11 day training (Table 1). Of all the trainees, 432 of them received the training during the fourth quarter. The second phase of IRT covers the modules on MCDs, NCDs and Basic First Aid and will take place during the first quarter of FY18. The rollout trainings will be jointly organized by the government and SEUHP; the FMOH will cover per diem and related expenses while SEUHP will provide training manuals and ensure the quality of the trainings.

In all SEUHP-supported regions, the regional teams and SEUHP staff played critical roles in scheduling and monitoring the quality of IRT. Skilled facilitators who work for government had participated in TOTs led the training sessions and were able to apply competency-based training approaches using the standard IRT modules. The feedback from trainees showed a majority of them were highly motivated by and happy with the training, and, for many trainees, it was the first well-organized modular training they had ever received. They believed the training will increase their ability and confidence to carry out their day-to-day activities. To ensure quality of the training, national and regional IRT supervisory teams conducted structured visits to the sites during the training. The national team supervised eight sites in Addis Ababa, while a joint RHB/SEUHP supervisory team visited six other sites in Oromia.

According to the findings of these visits, the majority of training sites have fulfilled the following major requirements:  Provided adequate training modules (Facilitator‘s Guide and Participant‘s Manual).  Arranged training venues with adequate space, good ventilation and light, which were free of noises.  Engaged all expected trainees.  Applied the standard participatory competency-based methods during the training sessions.  Deployed skilled facilitators in the required number and specialty.  Covered all three training modules within the given period of time.

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Table 1: Integrated Refresher Training by regions and category of the trainees, Oct. 2016-Sept. 2017

Q4 FY17 Total

UHE- Super Supervis Region M F Others* Total M F UHE-Ps Others* Total Ps visors -ors Addis 40 764 655 118 31 804 Ababa 0 Amhara 37 37 37 30 314 294 24 26 344 Dire 10 112 112 10 0 122 Dawa 0 Harar 68 68 7 0 68 0 68 68 7 0 75 Oromia 8 319 307 17 3 327 12 444 431 20 5 456 SNNP 0 0 298 298 0 0 298 Tigray 0 0 200 200 0 0 200 Total 8 424 412 24 3 432 92 2200 2058 179 62 2299 * Participants from town health offices, health centers, and other government health offices

1.1.3 Provided post-training skill reinforcement support to the UHE-ps

As part of the IRT package, trainees receive on-the-job, follow-up support for six-to-eight weeks after the training with the aim of encouraging knowledge retention and reinforcing the skills acquired during the IRT. In final quarter of FY17, the Oromia regional team conducted post-training follow-up visits in Shashemene, Gimbi, and Bishoftu towns. The follow-up was performed by a team from the respective town health office (THO) trainers and SEUHP cluster coordinators using pre-prepared checklist. During the follow-up visits, the teams learned that most of the UHE-ps found the IRT approach very helpful to them in improving their knowledge and skills.

UHE-ps have started applying the knowledge and skills they acquired from the training in their daily practice. For instance, UHE-ps at Shashemene town started planning for open defection-free ketenas, while UHE-ps at Bishoftu town mobilized communities at two sites and helped them construct liquid waste drainage at a site that previously used as a garbage site. UHE-ps from Gimbi town noted that the IRT has increased their confidence and knowledge and motivated them to provide increased services to the community. The WASH module helped them support households in the construction of latrines while the RMNCH module increased their skills in counseling HIV positive mothers and on infant feeding options, with an emphasis on the importance of exclusive breast-feeding

1.1.4 Creating enabling work environment for UHE-ps

Existing evidence has shown that the level of motivation and job satisfaction of the UHE-ps is generally low, mainly attributable to a lack of a clear management support system and a limited budget for supplies. In order to help the UHE-ps provide high-quality public health services in homes, schools, and youth centers, SEUHP has been implementing several non-financial motivational schemes.

The Amhara SEUHP team conducted a rapid assessment to identify the major need gaps of the UHE-ps during the first quarter. The assessment findings show that only 40% of UHE-ps have separate office chairs and tables, and 90% have no functional blood pressure monitoring apparatuses, thermometer or infant weight scales. A lack of lockers and file boxes to store recording tools was also found to be a major problem for the UHE-ps. Only 50% of UHE-ps have separate office space, and many offices need - 17 -

roof/ceiling maintenance, painting, window/door maintenance, or floor cementing. UHE-ps without offices either share with other government offices or don‘t have office space at all. Dipsticks for pregnancy and diabetes testing, paracetamol, RDT for malaria and malaria drugs and water treatment chemicals were not available although they are listed as necessary in the revised UHEP implementation manual. These gaps are major discouraging factors to the UHE-ps that need to be addressed.

The provision of equipment helped improve UHE-ps‘ acceptance by the community and their ability to provide diversified services. Thus UHE-ps who have equipment are motivated to exercise their expertise as clinicians. SEUHP has been also doing advocacy work at all levels to ensure UHE-ps have the necessary supplies and support and are motivated and capacitated to provide high quality services.

The team in Oromia undertook key activities to rehabilitate the existing model UHEP center in Adama with the goal of establishing a learning center. The model UHEP center at Kebele 08 is now equipped with a computer and printer and other office supplies. Based on identified skill gaps, three out of four UHE-ps working at the model center were supported to take basic computer training. SEUHP shared the importance of performance-based recognition as a motivational factor to the respective THOs. THOs used their own budgets to recognize the three best performing UHE-ps, along with their kebeles and health centers, during the annual review meeting event SEUHP provided a desktop computer with printer for the best performer health center at Adama and provided one desktop computer for each of Dembela and Adama health centers. SEUHP had technically supported the development of performance evaluation checklists which are used by performance evaluation teams to identify best performing sites. Minor renovations of seven UHE-ps‘ offices was also done in Adama (Kebele 04 and 09), Shashemene (Bulchana Kebele), Jimma (Awetu Mendera Kebele), Batu (Kebele 01 and 02) and Nekemte (Kesso sub city) during the third and fourth quarter of FY17.

Picture 2: Before and after maintenance photo of Jimma Awetu kebele UHE-ps office

SNNPR regional SEUHP team, in collaboration with the respective THOs, HCs, and the UHE-ps, renovated the UHE-ps‘ offices at Damota Kebele in Soddo, Dilla town (Buno and Boiti kebeles), and Durame (Lalo Kebele) towns. The renovation included the provision of office furniture (office chairs, tables and shelves) for two of the renovated offices based on their prioritization with respect to their status/problem.

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Overall in FY17, to address the challenges related to lack of supplies, SEUHP purchased and distributed more than 2300 nursing-bags, 2300 thermometers and 1920 blood pressure measuring apparatuses with stethoscopes to UHE-ps in the seven SEUHP supported regions. The handover of the supplies/equipment purchased for all of the regions was conducted in the presence of government health officials, UHE-ps, health center staff, administrators and others. In addition, discussions were held with the State Minister of Health, Dr. Kebede Worku, and heads of the regional health bureaus to facilitate government budgeting for similar support to UHE-ps not supported by SEUHP.

Following the distribution of the working tools, SEUHP regional teams supported and monitored UHE- ps on the proper use of equipment and supplies. UHE-ps are now able to provide health services to their clients using the supplies and equipment; including measuring blood pressure for postnatal mothers, hypertensive cases and people with related risk factors. This, in turn, helped the UHE-ps earn more acceptance in the community.

Sub IR 1.2: Improve UHE-p access to standard health service packages and service delivery manuals

1.2.1 Prepare package of UHEP reference manuals and guidelines and make them available for UHE-ps at their duty station

Although UHEP implementation tools and guidelines were developed in FY15, they are rarely found at health offices or health centers, nor do UHE-ps have them in their possession. In FY17, SEUHP prepared a package with all the necessary reference manuals and guidelines for UHEP implementation; and provided orientation and kept it at the health centers and UHE-ps Picture 3: Urban health extension professional supported by SEUHP duty stations for day-to-day educating community member referring the toolkit provided by SEUHP use. ; Based on feedback from the field and the revised implementation manual, the SEUHP central office technical team revised some contents of the toolkits accordingly. The toolkits are comprised of SOPs, algorithms, flowcharts, etc., on major public health programs such as MNCH, EPI, FP, Nutrition, HIV/AIDS, TB, IEC/BCC and WASH. Accordingly, parts of the MNCH, HIV/ AIDS and WASH toolkits have been updated and are being printed. The toolkits will be integrated with other job aids and tools in a binder and will be distributed to the UHE-ps in the next quarter. In order to help the regional SEUHP staff internalize the targeted HTC approach and to standardize targeted testing across the regions, a quick HTC guideline was developed and shared with all regional staff.

1.2.2 Roll out the revised UHEP implementation manual

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SEUHP has been playing a key role in developing, printing, and distributing the UHEP implementation manual (IM), along with orientation followed by regular monitoring of its implementation. It is critically important to follow-up the implementation of key recommendations in the revised UHEP manual as this would ensure that UHE-ps are providing services as per the standard with the support from the respective HCs. In FY17, SEUHP regional teams advocated for monitoring use of the revised IM when conducting supportive supervision visits (SSVs) and performance review meetings. As a result, improvements have been observed through the course of the year.

Amhara: UHE-ps now identify pregnant mothers and under-1 children and follow them closely with separate registrations to ensure MNCH services are provided at the HC level. UHE-ps are receiving supplies and equipment based on the manual, although dipsticks for diabetics and pregnancy tests are still missing. All health centers have assigned UHEP focal persons based on the implementation manual and provide support on weekly basis in the community. Weekly performance review meetings are also in place. Though the implementation status differs across towns, mapping of the targets and service needs is being done. Service provision to homeless people has started in Bahir Dar and Finote Selam towns.

SNNPR: In some of the SEUHP supported towns, use of the revised IM is promising as it is observed during the field visits by CCs and the regional team. For instance, UHE-ps have started using the IM as a reference for their day-to-day activities; the UHE-ps are supervised by their catchment HCs both administratively and technically; UHE-ps started to provide limited clinical services beyond the health education activities; UHE-ps are collecting household profiles as baseline data and identifying priority populations for their service provision.

Tigray: The RHB has customized and endorsed the revised UHEP implementation manual. SEUHP supported the translation of the manual into the Tigrigna language and subsequent printing. The SEUHP regional team also organized a workshop for familiarization/orientation on the revised IM for stakeholders. Ninety-nine individuals attended the orientation workshop.

Oromia: The contextualized Afan Oromo version of the revised UHEP IM was endorsed by the head of the Oromia RHB. SEUHP facilitated the printing and duplication of the revised manual. About 1000 Afaan Oromo copies of the revised implementation manual were printed. The manual was launched during the regional Bi-annual Review Meeting. The SEUHP regional team, in collaboration with the RHB, organized familiarization/orientation workshops on the revised IM for stakeholders across the SEUHP intervention towns in the region. A total of 788 representatives of HC staff, THOs, other urban health stakeholders and UHE-ps attended the workshop. The main purpose of the orientation was to familiarize the stakeholders with their roles and responsibilities stated in the implantation manual. Following the familiarization workshop, activities such as provision of HCG tests, diagnosis of diabetic mellitus (DM) using dipstick urine tests, and iron foliate supplementation for pregnant women were included the work plans of some towns. However, there is currently no clear guidance on how health centers should provide supplies to undertake the above mentioned activities as they are not free-of-charge services as it will be difficult for UHE-ps to manage the billing system at community level. In Oromia, 14 of the 35 health centers supported by SEUHP assigned a UHEP focal person.

Addis Ababa, Harar and Dire Dawa Since the implementation of the revised urban IM, Harar and Dire Dawa have started integrating the UHE-ps and health centers by bringing the UHE-ps to health

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centers to strength the relationship between them. The Addis Ababa (AA) SEUHP regional team supported the printing and distribution of 1,500 revised UHEP IMs.

Sub IR 1.3: Improve implementation of quality improvement initiatives

1.3.1 Advance the quality improvement initiative in 63 health centers and expand to eight new HCs

SEUHP is working with HCs that are implementing quality improvement initiatives (QIIs) to strengthen measurement practices and root-cause analyses by providing refresher trainings and on-the-job technical support. The QIIs aim to improve the quality of services and performance at the PHCU level by forming teams to respond to UHE-p needs. Teams are comprised of the HC UHE-p focal person, UHE-ps, UHE-p supervisors, HC management, and experts from the respective city/town health office (C/THO).

Major activities performed during FY17 are the followings:

New QI teams established: In the first quarter of FY17, seven new QI teams (one in Oromia, three in SNNPR, and three in Amhara) were established by training 99 QI team members (33 males and 66 females). In the second quarter, a total of three new QI teams (two in Oromia and one in SNNPR) were established and provided with basic training on QI. This brings the total number of new QI teams established to 10 (125% of the annual target). Overall, in the first two quarters, 146 individuals (48 males and 98 females) participated the basic QI training. The training covered the basics of quality service delivery, systems thinking, identification of weaknesses/quality related problems, tools of quality improvement, measurement of QI, process analysis (root cause analysis), prioritization, and the development of action plans. Participants in the basic QI training were supported to develop a six- month plan of action.

Refresher trainings provided to QI teams: In FY17, refresher training sessions were organized for 60 out of 63 QITs. Participants were from all SEUHP operational regions: Addis Ababa, Harar, Amhara, Dire Dawa, SNNPR, Oromia, and Tigray. A total of 898 individuals (64% females) received refresher training on quality improvement (Table 2). Most of the trainings (84.5%) were conducted during the first half of FY17. The first half day of the training session covered the status QI implementation, achievements, and challenges encountered and how to address challenges to further improve the QII. Improvement objectives were revised and incorporated in the action plans.

Review meeting conducted: During the reporting year, 27 QIT review meetings were organized in the respective regions of Amhara (9), Addis Ababa (11), Dire Dawa (3), and Harar (4). A total of 307 individuals (61.2% females) participated in the review meetings. The review meetings were facilitated by government health experts with the support of the SEUHP team. During the review meetings, QITs reviewed their QII performance and, based on the findings, developed action plans to address gaps identified through the QI process. The review meetings are an important platform for QITs to share experiences and learn from other teams.

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Table 2: QI review meeting and refresher training participants by region and sex, Oct. 2016 - Sept. 2017

Review meeting participants Refresher training participants Region # of QIT Male Female Total # of QIT Male Female Total Addis Ababa 11 46 85 131 9 43 83 126 Amhara 9 42 46 88 12 61 94 155 Dire Dawa 3 12 15 27 3 10 17 27 Harar 4 19 42 61 5 23 37 60 Oromia 0 0 0 0 11 53 123 176 SNNPR 0 0 0 0 9 70 124 194 Tigray 0 0 0 0 11 59 98 160 Total 27 119 188 307 60 321 576 898

Experience sharing visits conducted: Structured experience sharing visits were organized in Addis Ababa and Harar. In Addis Ababa, three events were organized and 97 individuals from the nine QITs participated. In Harar, an experience sharing visit was organized at Arategna HC for 61 visitors (19 male and 42 female) from three HCs, woreda health offices, and RHBs. The host team presented improvement processes and discussed the progress achieved. The experience sharing visits were effective in activating the visitors‘ commitment and enhancing achievements.

Site visits conducted: In this reporting period, the SEUHP team, along with the respective THO experts, conducted QI site visits and provided technical support to build QIT capacity. SEHUP has focused on building QITs‘ capacity to analyze the existing situation and identify problems; set targets for identified quality problems; document QI process and outcomes; and to measure progress.

The Changes observed through implementation of QII are outlined as follows:

Amhara: The regional average for the percentage of complete referrals was 36%. But in the three QI implementing HCs in Debre Markos town, the percentage of complete referrals was much higher than the regional average: Debre Markos HC (41%), Hidassie (70%), and Wuseta (68%). In Amhara region, the number of referrals and completed referrals has increased from the previous quarter by 47% and 54%, respectively.

Oromia: SEUHP has been closely monitoring and providing support for the respective QITs in different towns. The QII resulted in significant improvements in referral linkages, and the demand for and use of health services increased. For example, in Dembel HC (Batu town), performances on referral linkages improved from 41% to 86%, child immunization improved from 40% to 60%, institutional delivery improved from 14% to 32%, ANC1 visits improved from 45% to 96%, and ANC4 visits improved from 18% to 50 In Nekemete HC (Nekemete Town), the QIT initiated monthly meetings and began measuring performance indicators on defaulter tracing, using referral slips, and providing feedback to UHE-ps. QIT at Nekemte showed remarkable progress in tracing and linking defaulters. In FY17, at Nekemte HC, the number of cases traced and referred increased from 3 in the first quarter to 59 in the fourth quarter. The provision of feedback on referred cases has also improved.

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Fig. 1: The contribution of the QII on improving defaulter tracing, referral and linkage in Nekemete HC; Oct. 2016-Sept. 2017

SNNPR: The QIT in Butajira and Wolayta Sodo demonstrated strong and committed leadership by replicating the QII for all the PHCU services. As a result, the health services have shown improvements and better platform has been created integrating community and health facility level health care services. The QI teams conducted regular monthly meetings. The QITs made an arrangement to minimize the waiting time for clients visiting the HC using three-colored cards to identify the clients as emergency, priority and normal. In addition, the cash collection mechanism has been arranged to minimize the waiting time of clients in records room, laboratory and pharmacy units.

Addis Ababa: In Addis Ababa, improvements were observed in the number of completed referrals between October 2016 and March 2017 (Fig. 2). A field guide was prepared and shared for the field staff to strengthen the documentation of field level quality improvement experience and lesson learned.

Fig 2: Woreda 11 Health center, Lafto Sub City, Addis Ababa

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Institutionalizing the QII: To ensure that the QII is effectively introduced at all levels of the health care system, SEUHP has been working to transfer leadership of QII to the FMOH and RHBs. In this regard, the RHBs in Harar, Dire Dawa, and Addis Ababa have been involved in QII activities including monitoring of QII efforts through monitoring visits, review meeting, and experience sharing visits. QIT assign referral and defaulter tracing focal persons at the HC level. In Amhara, Hidasse HC integrated the QI activities into the HCs work plan and shared them with the THO. The SEUHP Central Office (CO) team is also closely working with the National Quality Improvement Steering Committee. To support the sustainability of ongoing quality improvement efforts, the engagement and buy-in of the FMOH and its respective structures at various levels is essential. In this regard, SEUHP‘s QII is included in the national Quality of Care (QOC) network activity mapping. SEUHP facilitated QI site visits for FMOH personnel in Addis Ababa, Bishoftu and Harar. Discussions were held with the FMOH to develop Quality Improvement Guidelines for Community health services based on the existing experience and in collaboration with other partners that support community-based QI. Overall, QIIs are playing an important role in improving the performance of the UHE-ps through improved working relationships within the HC teams.

Sub IR 1.4: Improve referral and linkages between UHE‐ps and facilities

UHE-ps‘ main role in the urban setting is to facilitate referrals for care at primary health care centers. SEUHP introduced a referral system for UHE-ps to initiate referrals from the community to HCs; and developed referral guidelines, a toolkit, and a service directory, which are being used in all SEUHP- supported towns/cities with the aim of increasing the proportion of completed referrals.

1.4.1 Standardize, institutionalize, and operationalize referrals into the government system

Integrating health services is an important way to make service delivery more efficient for the health system and more accessible for clients, as well as for improving individual and family health outcomes. While referral systems may exist at the national level, referral networks tend to be contained within smaller geographical areas, such as sub cities and Kebeles. For the referral system to be functional it is essential to have well established referral networks with clear protocols and guidelines. In this regard, during this reporting period SEUHP, together with FMOH‘s Primary Health Care and Health Extension Program Directorate, has taken a lead in establishing the urban referral taskforce at the FMOH. The key role of the task force is to develop comprehensive referral guidelines which can be used by the PHCU and UHE-ps. The main objective of the guidelines is to make the overall referral system standardized and functional.

Referral services: In FY17, a total of 55,736 individuals (77.6% females) were referred for health and social services. These accounted for about 85.7% of the annual target. The majority of clients were referred for EPI/immunization services (24.4 %), followed by ANC services (14.7 %) and FP services (12.1%) services.

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Fig.3: Referrals made by type of service, Oct. 2016 - Sept. 2017

Referral feedback: Unlike referral services, referral feedback was low during the reporting period with only 36% (37% for the fourth quarter) of the total referrals having feedback documented by UHE- ps. Factors contributing to the poor feedback performance included clients‘ failure to go to HCs after receiving the referral slips from UHE-ps; clients‘ failure in bringing referral slips with them to the facility; lack of commitment by some HC staff to provide feedback; and poor collection mechanisms and documentation of the referral feedback in UHE-p daily activity registers. Though the proportion of completed referrals was low against the total number referred, the performance against the annual plan was 81.7% while it was 91.8% for the fourth quarter (Fig. 4).

Fig.4: Performance on referrals and completed referrals, Oct. 2016 - March 2017

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Sub IR 1.5: Increase access and coverage of HIV prevention, treatment, and care services

1.5.1 Enable UHE-ps to provide standardized HIV-prevention services to key populations with effective referral to health centers for further care and support

Ethiopia‘s FMOH has been conducting national HTC catch up campaigns since the end 2016 with the aim of achieving the 90-90-90 target and positioning the country for a reliable level and pace to achieve this target. One of the mechanisms devised to achieve this goal was to identifying high burden geographic sites and community groups, mobilizing them for targeted HTC, ensuring access to HTC for them, and strengthening linkages to care and treatment for HIV positive individuals.

During the first reporting quarter, a job aid (Targeted HIV Testing, Care and Support: A Quick Field Guide) was drafted for SEUHP field staff (regional managers, public health advisors, monitoring and evaluation advisors, and cluster coordinators) who are largely involved in helping the UHE-ps conduct targeted HIV testing and referral services. The guide‘s main purpose is to help make the staff more organized and skillful while helping the UHE-ps, their supervisors, and other stakeholder in the effort of reaching Most at Risk Populations (MARPs) with targeted HIV testing, care and support.

SEUHP supported UHE-ps to accelerate targeted testing with different strategies: updating the profile of the catchment populations with focus on priority populations for HTC, using PLHIV associations data and chronic care data from health centers to identify index cases, enhancing routine household visits, using model families and Health Development Armies (HDAs), and using men and women in Idir (community based self-help) for identifying priority populations (widowed, divorced, separated, index cases). Following the Site Improvement through Monitoring System (SIMS) visits conducted by USAID, proficiency testing was checked on HIV test kits by laboratory professionals using batches of HIV test kits with blood samples of known positive and negative results. Guidance was also circulated to cluster coordinators (CCs) to implement proficiency testing at the UHE-p level and to conduct quality assurance for the testing done by UHE-ps.

In FY17, SEUHP organized a two-day training for 664 UHE-ps and HC staff (133 from Amhara, 362 from SNNPR, and 169 from Tigray) on the new HIV testing algorithm. The training equipped the UHE- ps with practical skills on using the new HIV test kits. To ensure the quality of HIV testing conducted by the UHE-ps, proficiency testing was conducted using the laboratory professionals using with blood samples of known positive and negative results Moreover, guidance was also circulated to cluster coordinators (CCs) to implement proficiency testing at the UHE-p level and to conduct quality assurance for the testing done by UHE-ps.

With the exception of the Addis Ababa City Administration, all of the six SEUHP-supported regions are now providing community/home-based HTC service. After repeated consultative meetings and discussions with the RHB, the Tigray regional SEUHP team succeeded in initiating home-based HTC services in April 2017. Similarly, the Addis Ababa SEUHP team prepared a concept paper and held consultative meetings with the RHB to start home-based HCT services.

In FY17, a total of 21,834 individuals received HIV testing and counseling services by UHE-ps accounting for 240.7% of the annual target. Such an over-achievement was recorded because of the HIV catch up campaign‘s huge mobilization efforts. The total number of HIV positive cases was 374

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resulting in a yield of 1.71% (2.03% among females and 1.17% among males). A total of 2100 individuals were tested in quarter four accounting for 87.5% of the quarter target with 1.33% positivity rate.

Table 3: Clients received HIV testing and counseling (HTC) services by test result, age-sex and regional distribution, Oct. 2016- Sept. 2017

HTC Q 4 FY17 Total Male Female Total Male Female Total Tested 1,546 2,100 554 21834 7962 13872 Total: Negative 2,072 1,521 21460 7869 13591 551 Age/sex: 10-14 59 2147 967 1180 103 44 Age/sex: 15-19 314 3983 1339 2644 403 89 Age/sex: 20-24 495 5161 1845 3316 608 113 Age/sex: 25-49 630 9572 3452 6120 921 291 Age/sex: 50+ 23 597 266 331 37 14 Total: Positive 25 374 93 281 28 3 Age/sex: 10-14 - - 21 7 14 - Age/sex: 15-19 3 25 4 21 3 - Age/sex: 20-24 4 47 5 42 4 - Age/sex: 25-49 15 258 72 186 18 3 Age/sex: 50+ 3 23 5 18 3 - Yield (%) 1.33 1.71

Looking at HIV test results by subpopulation in this reporting quarter, the highest HIV positivity was recorded among the widowed (3.75%), followed by divorcees (3.28%) and sex workers (3.24%).

Figure 5: HIV testing and counseling services by population characteristics and target groups, Oct. 2016 – Sept. 2017

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Sub IR 1.6: Strengthen TB case detection and increase treatment success rate by implementing community TB care interventions

1.6.1 Continue working with CHALLENGE TB program to collaborate and synergize activities in the areas of TB interventions.

SEUHP distributed reference toolkits that include a presumptive TB checklist to help the UHE-ps to undertake community-based TB screening. SEUHP also provided mentoring and supported the UHE-ps to utilize the screening checklist. In FY17, SEUHP made efforts to partner with the CHALLENGE TB program. The main purpose of the partnership was to leverage efforts/resources towards curbing TB in urban settings. Accordingly, areas of common interest were identified, coordinators were selected from both organizations and a TOR finalized. In FY18, more attention will be given to community TB care services because it is part of the second phase IRT package which will be cascaded in the first and second quarters of FY18.

Sub IR1.7: Increase access, coverage, and use of high-impact MNCH services

1.7.1 Enable UHE-ps to provide ANC and PNC services and increase uptake of skilled delivery among hard-to-reach population groups

In urban areas, there are segments of the population that cannot access health services due to their socio-cultural and economic circumstances. It is important to create access to health services for hard- to-reach populations and so SEUHP has been working with the relevant RHBs and THOs to engage the UHE-ps to provide health services to these populations. A brief guide that helps to implement access for health services for hard-to-reach segments of the population was prepared by the CO and shared with regional teams. The regional teams conducted discussions with the respective THOs to implement the interventions through mapping hard-to-reach population. In line with the UHEP IM, during the fourth quarter of FY17, health services for hard-to-reach population have been provided in Reaching urban vulnerable people Bahir Dar, Finote Selam, and Gondar towns. The beneficiaries include 62 homeless families residing on the streets in Bahir Dar About 62 families of homeless population (Tana sub-city). Family planning, ANC follow-up, and post-natal residing at streets in Bahir Dar (Tana sub- care services were provided at Finote Selam Town (Kebele 03) for City) received Health Education on Hygiene and Sanitation, and direct services such as women sheltered in the church vicinity. UHE-ps in Finote Selam immunization, bed net distribution, De- also treated individuals sheltered at churches for scabies and worming, Vitamin A supplementation, referred cases to nearby health facilities for those that needed nutrition screening to mothers and children further care and services. Similarly, in Jimma town UHE-ps started and care and support for chronic diseases. to conduct reproductive health and family planning services for Family planning, ANC follow, post-natal care people with disabilities, and four individuals with a disability services were provided at Finote Selam received family planning and other reproductive health services Town (Kebele 03) for women sheltered at through referral and direct service provision. church vicinity. In Addis Ababa the SEUHP regional team, in consultation with AA RHB, identified four potentially hard-to-reach‖ sites: one in Woreda 9 of Kolfe Karanio sub-city, one in Woreda 10 of Yeka sub-city, and two each in Woredas 5 and 10 of Arada sub-city. SEUHP held a series of discussions and developed an action plan with the respective Woreda Health Offices (WorHOs) to identify the needs of clients living in these hard-to- reach areas and how to reach them with the required services.

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Sub IR 1.8: Increase access to FP/RH and AYRH services

According to the revised implementation manual, UHE-ps are expected to exert more effort in MNCH services in general and antenatal care (ANC), adolescent and young people‘s reproductive health (AYRH), and home-based postnatal care (PNC) services in particular. To support the UHE-ps in undertaking targeted and patient-based MNCH services, ,SEUHP has developed MNCH-related training materials, job aid guides, scopes of practice, protocols, and behavior change communication tools and distributed them to UHE-ps with orientation and follow-up on their utilization.

In FY17, UHE-ps received technical support on how to identify pregnant women and help them access health service at facilities by providing registers for pregnant mothers and children of under1year of age. This has been helpful for registering and following up mothers for ANC/PMTCT, institutional delivery, PNC, nutritional screening, and immunization.

SEUHP has been working hard to ensure the UHE-ps provide home based postnatal services through providing technical capacity building and supplying equipment. PNC services include physical examination /check-up of the mother and new born, temperature and BP measurement for mothers. In Oromia, the continuous regional SEUHP team support enabled UHE-ps to provide PNC (within the first seven days postpartum) services. In the reporting quarter, UHE-ps in Shashemene town identified and provided home based PNC for 46 mothers and screened 2,412 under-five children for malnutrition.

Pregnant mothers‘ conferences have been conducted regularly and during the conferences, UHE-ps measured blood pressure, provided nutritional screening, and distributed FHCs in addition to providing health education.

Llimited access to reproductive health information and a lack of quality adolescent and youth-friendly reproductive health services are major bottlenecks to ensure universal reproductive health services. During the reporting period, SEUHP prepared a hand-out on youth-friendly services (YFS) for program staff as a quick reference guide for organizing trainings for adolescents and youth as well as for supporting UHE-ps to address adolescent and youth matters. The hand-out was prepared based on the adolescent and youth reproductive health blended learning module of the health extension programme. In this regard, the Amhara SEUHP team organized a two-day school health training for WASH club members in one of the selected schools (Ewuket Fana primary school) in Bahir Dar city. A total of 30 individuals (five teachers and 25 students) were trained. At the end of the training, an action plan was developed by the students and their teachers. Similarly, students and teachers that are school club members at Tsadiku Yohannes‘s primary school in Gondar Town received a two-day training. The training focused on first aid and UHEP packages giving with a focus on AYRH. A total of 27 individuals (23 students, two teachers, one UHE-p and the school director) were trained. During the reporting period, with technical support from SEUHP, UHE-ps provided direct services to 164,162 individuals (112% of the target) in the 49 targeted cities/towns. Direct services focused on HTC, referrals for access to services, nutritional screening, suspected TB case identification, PNC, FP, EPI, condom distribution, etc. The table below provides a summary of individuals reached with direct services and through referrals for both the annual and fourth quarter performance.

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Table 4: Clients reached with direct MNCH services provided by UHE-ps from Oct 2016 – Sept, 2017 FY17 FY17 FY17 Perfor FY17 Q4 FY17 Q4 FY17 Achiev mance Q4 Achiev Performa Service indicators Target ement (%) Target ement nce (%) Number of individuals reached with direct services from UHE-ps (excluding health education) 580,852 641,936 111% 146,445 164,162 112% Number of individuals referred to facility for access to services in the reporting period 66,002 55,736 85.7% 15,167 14,494 95.6% Number of completed referrals documented in the reporting period 24,404 19,946 81.7% 5,814 5,338 91.8% Number of defaulters identified and linked to health facilities for continuity of services 4,006 2,004 50.7% 941 477 55%

Overall, as a result of the IRT and continuous follow-up support through on-the-job technical assistance provided by SEUHP‘s technical team, most UHE-ps are now able to identify pregnant mothers; take gestational history and calculate expected date of delivery; counsel pregnant women on maternal nutrition and hygiene including birth preparedness; assist pregnant women through ANC and institutional delivery; follow-up with pregnant women on the prevention of mother-to-child transmission of HIV; provide home-based PNC; provide child growth monitoring and promotion services; follow-up on immunization services and promote participation in deworming campaigns; and trace defaulters and link them to HCs for further care and support.

Sub IR 1.9: Support FMOH and RHBs in the implementation of PHCU reform

Primary health care reform (PHCR) aims to ensure universal health coverage (UHC) for all citizens through a primary health care system run by interdisciplinary family health teams. Over the past year, a pilot program has been implemented in three health centers in Addis Ababa with the collaborative effort of SEUHP and Addis Ababa RHB. Based on the lessons learned from the FY16 pilot PHC reform sites in Addis Ababa, in FY17 the FMOH planned to scale up the program to more PHCUs in Addis Ababa and six other regional towns.

In FY17, SEUHP provided multi-faceted support for the RHBs and the respective town health offices. A total of 873 Family Health Team (FHT) members (495 male and 378 female) attended the training. Topics covered during training were; the concept of primary health care reform; planning, monitoring and evaluation; data recording and reporting; community mobilization and interpersonal communication; and supply chain management. This training aimed at enabling the FHT to provide comprehensive primary health care services with optimal quality at the health facility, household, and community levels. Some of the activities performed in FY17 are presented by region as follows:

Addis Ababa: The regional team provided continuous and frequent technical support to facilitate the health center preparation and to enable the FHT to start providing community health services. The FHT at Nifas Silk woreda 06 Health Center reached 164 HH and two schools and provided health care services for 332 individuals. In doing so, the team was able to address the needy segment of the population who are poor and as well as having either health problem or susceptibility for health

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problems. Likewise, towards the end of FY17, the FHT at Dressing code for FHT Janmeda, Semien and Nifas Silk Lafto woreda 12 HCs have In consultation with the regional started providing community based health care services. Health Bureau, a dressing code was tested in Addis Ababa for the In the fourth quarter of FY17, refresher training was organized FHT. Thus, the FHT members (45 for Entoto # 2 health center to revitalize the implementation individuals) at Janmeda health status to its optimal level. A total of 70 participants (Female 49 center were provided with and Male 21) who are members of FHT attended the training. uniform made specific for the Besides, preparation of implementation guide line, home/community-based services. development of referral slips for family health team, household This will enable the FHT to have level service data recording card, FHT weekly monitoring professional dressing while visiting tools, FHT weekly planner for UHEP and FHT coordinator the households, schools, and report aggregation tools and application for data collection outreach sites. have been developed.

The SEUHP team also focused on supporting on areas of supportive supervision to establish proper multidisciplinary FHTs, data base utilization, and provision of community based health care services and weekly monitoring mechanisms. As a result, 498 clients had received health care services from the FHT at Nifasilk Lafto Woreda 06 health center in households, schools, workplaces, outreach sites, and youth centers.

Harar: The family health teams of the three Kebeles finalized their plans and started implementing community health services after analyzing the baseline data. The necessary supplies and medical equipment were provided by the health center. The FHT provided long term family planning, postnatal care, NCD screening, and did tracing of unimmunized children and linked them to the health center. The teams conducted weekly meetings to discuss the status of intervention and next steps.

Dire Dawa: A three-day workshop was organized to contextualize the reform implementation manual and training was provided for 47 participants from Addis Ketema HC (40) and RHB (7). Addis Ketema HC has conducted baseline data collection, and data entry is started.

Amhara: SEUHP identified Bahir Dar HC as the PHC reform implementation site and adapted the implementation manual to the local context including the data collection tools. Orientation was provided to 40 HC staff members on the objectives and implementation strategies of the reform. A two-day orientation was provided for UHE-ps and data collection started on March 13, 2017. The baseline data collection process was finalized and UHE-ps have prepared their annual plans while the data entry is simultaneously taking place. One of the four teams organized as a Family Health Team has begun providing service in the community. During the follow up support, it was observed that in one catchment area three pregnant women, two women with infants, one woman on ART were supported by the FHT. A shortage of human resources and high patient volume at the HC are the major reasons for the delayed implementation of the reform.

Oromia: The region adapted the implementation manual to the local context and data collection tools were translated into the local language. Jimma HC was selected to be the pilot site for the PHC reform, where orientation was provided for the management team and a joint implementation plan was developed. A technical working group that will support the implementation of the reform has been established at regional level.

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During the third quarter of this implementation period, a one-day sensitization workshop was conducted on PHCU reform and its implementation strategies, as well as about the role of stakeholders. A total of 47 participants (20 male and 27 female) from Jimma HC, THO, UHE-ps, education office, city administration, political leaders, women and children affairs office, and kebele managers attended the workshop. Three FHTs were formed with members including; health officers, nurses, and environmental health officers, midwifes clinical nurses, pharmacist, laboratory technicians, and UHE-ps. Based on the available professional mix, the number of staff in the health center, and number of kebeles; each team is assigned for 2,000 to 3,000 households (HHs) in their catchment kebeles. Environmental health officers and nurses were hired to solve existing staff shortages. The database has been developed in Afan Oromo and training was provided for seven staff members. SEUHP provided two desktop computers for the HC and data entry has already started.

SNNPR: In the first quarter, SNNPR established a central core team consisting of SNNPR RHB/Disease Prevention and Health Promotion Core Process staff; RHB/HEP case team officers; the head of Hawassa City Administration Health Department and DPHP officers; the Millennium Health Center director; DPHP case team leader; and the JSI/SEUHP regional office staff. The core team also developed a piloting plan. About 35 individuals from the RHB, Hawassa City Health Department and Millennium HC attended a one-day orientation workshop on the reform process. In the second reporting quarter, the team conducted experience sharing visits to Addis Ababa before starting work on the expansion of the reform to the regional context. The region established a central core team to lead the reform process consisting of different actors from the RHB, Hawassa City health office, SEUHP regional office, and the selected health center (Hawassa Millennium HC). The core team developed an action plan to monitor the progress. A one-day orientation was organized on the concept of PHC reform for 35 individuals from the RHB, Hawassa City Health Department, and Millennium HC.

A one-day training was also provided for 42 participants (UHE-ps, their supervisors, and the HC FHT members) on baseline data collection tools and baseline data collection was finalized. To enhance the startup of the PHCR implementation, the SEUHP regional team will provide close follow up to facilitate the data analysis and its use for action and to fulfill office furniture‘s and the necessary tool kits for the FHT.

Tigray: A Family Health Team composed of five health professionals was established in Wukero town. The team has developed a work plan for PHCR implementation and began to provide community health services to pregnant women and children as priority groups. The FHT undertook pregnant mothers counseling regarding the danger signs during pregnancy, ANC follow up, benefits of taking iron/folic supplementation during pregnancy including dietary advice, birth preparedness and institutional delivery, linking pregnant mothers to HCs for ANC, and nutrition screening for pregnant mothers and children.

Since its establishment, the FHT has reached a total of 321 HHs and provided key health messages and services for 98 pregnant women and conducted nutritional screening for 82 pregnant women and ten postnatal visits. Likewise, deworming services have been provided to 52 children and vitamin A supplementation has been provided to 77 children.

Unlike the other regions, the FHT at Wukro started providing services before collecting baseline data. This has affected its efficiency since categorization, which is associated to socio-economic status, hasn‘t met the standards of the implementation manual. This has signaled for the need to conduct a baseline

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assessment. The other challenge observed in the implementation of the PHCR was a shortage of basic supplies such as BP apparatus, stethoscopes, and thermometers to provide comprehensive services. Failure to assign PHCU reform focal persons at facility and C/THO level is also a problem.

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PART 1.2: INCREASE DEMAND FOR FACILITY-LEVEL URBAN HEALTH SERVICES (IR 2)

As in previous implementation periods, in FY17, SEUHP continued supporting the efforts of the FMOH and RHBs to increase demand for urban health services. Support included the standardization of BCC job aids; the development of messages on key urban health issues including WASH, MNCH, HIV, and TB; the commitment to building the capacity of media professionals and increasing their involvement; and the contribution as a member of the behavior change communication working group.

Sub IR 2.1. Implement strategically designed behavior change communication

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interventions

2.1.1 Expand access to and utilization of IEC materials and tools focused on urban health priorities During the reporting period, SEUHP planned to increase access to improved IEC materials and BCC job aids for UHE-ps. To this end, the program has undertaken the following activities in collaboration with FMOH:

Rapid assessment on the utilization of the FHC: This initiative is part of the program‘s effort to improve effectiveness in BCC activities by making accessible BCC materials that are tailored to the urban context. An assessment was conducted to evaluate the utilization of family health cards (FHCs), identify gaps, and explore areas of improvement to cater to urban audiences. The assessment team was composed of five FMOH and four SEUHP staff. The assessments were conducted in Addis Ababa, Debre Markos, Hawassa, Mekelle, and Shashamene towns. The findings from the assessments are being used to develop the second generation job aids and health education materials for households. Recommended changes include integrating interpersonal communication processes into the tool, making the material a more manageable size, harmonizing messages, and expanding the content for NCD and WASH. The next step will be to conduct the content design workshop with FMOH, JHU/CCP, and other partners.

Development of a second generation SBCC job aid: As part of the effort to improve UHEP‘s ability to deliver quality service, SEUHP planned to initiate the development of a second generation SBCC job aid. The aim of this exercise was to map existing materials, assess their content (message and structure), and make improvements to address gaps identified during earlier field level assessment regarding the utilization of FHC. SEUHP conducted a four-day workshop (April 10-13) in Bishoftu attended by SEUHP, the FMOH, and partner organizations (JHU, Jhpiego, and fhi360). The output of the workshop included revising the contents of the messages in the FHC, which are currently in use. The group also agreed on a recommended standard structure to engage clients by UHE-ps. The revised version of the SBCC job aid will be developed in the following quarter.

Distribution of behavior change communication materials and job aids and follow up support: Enabling UHE-ps to provide ANC and PNC services and increase uptake of skilled delivery among key population groups is one of the strategies of SEUHP to support C/THOs, HC and UHE-ps. To this end the program distributed MNCH and WASH BCC job aids during the reporting period. The following activities were accomplished through the regional SEUHP teams.

Addis Ababa: As part of routine supportive supervision, the regional teams provided technical support to UHE-ps to improve the utilization of BCC materials. The regional team provided support in monitoring and technical support on the proper utilization of different job aid materials. After identifying new UHE-ps that did not have job aids, SEUHP distributed 424 copies of FHCs to ensure the availability and utilization of the BCC job aids. Furthermore, on-the-job training was given to UHE- ps to teach them how to use job-aids and other reference tools. During the reporting quarter, job aids were distributed for UHE-ps in Arada, Yeka, and Nifas silk Lafto sub-cities.

Harar: In Harar town, 2,750 FHCs were distributed to beneficiaries through UHE-ps during the regional level pregnant mothers‘ conference in addition to the 10 MNCH job aids provided to UHE-ps. In total, more than 1,800 FHC job aids were distributed to clients, through UHE-ps, to promote facility based services and positive health behaviors. In addition, a follow up on the utilization of MNCH job

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aids among the UHE-ps was conducted. The Harari SEUHP team provided orientation on the FHC during on job trainings and through supportive supervision.

Amhara: The utilization of job aids was assessed during supportive supervision in Bahir Dar, Kombolcha, Kemissie, Debre Markos, Debrebirhan, Injibara, Dessie and Gondar towns. It was observed that UHE-ps in Bahir Dar were using FHC, RMNCH and WASH job aids during HH visits. UHEP reference folders were also available in all UHE-ps office. In other target cities/towns, the job aid utilization and understanding has shown noticeable improvement through time. UHE-ps most often use the job aid while providing services at the community-level, HDA meetings, pregnant mother conferences and school health services. This improvement has come through coaching by SEUHP during routine supportive supervision.

Dire Dawa: In Dire Dawa, copies of UHEP Implementation manuals, MNCH counseling flip charts, WASH reference tools, pregnant mother registers, under-1 children register formats, PLHIV registers, daily service recording tools, and referral slips were distributed to UHE-ps, beneficiaries and HC staff.

SNNPR: In FY17, the SNNPR-SEUHP team distributed 134 MNCH-BCC job aids prepared by the central office. About 312 UHE-ps and 44 UHE-ps supervisors attended on-job orientation on the utilization of the job aid materials during supportive supervision visits by the program team. SNNP regional team also distributed 3,000 brochures and 15 posters during the Chambalala festival (New Year for Sidama tribe) at Hawassa town. Besides, the team distributed 5,500 copies of family health cards, 400 printed copies of the revised UHEP implementation manuals, and 88 full packages of UHE-ps reference materials to UHE-ps. In addition to CCs follow up, the RM and M&E Advisor visited two kebeles of UHE-ps in Butajira town and provided similar support on job aids and IEC/BCC materials utilization and handling. A total of 7 UHE-ps have received the support and the team observed that the current utilization of these materials is good, however some of UHE-ps still need routine follow up to develop it as a culture.

Tigray: In Tigray, SEUHP printed and distributed 114 Amharic version job aids (47 WASH and 67 MNCH) and 57 UHEP implementation manuals for UHE-ps at Mekelle, Adigrat, Aksum, Shire, Maychew and Alamata towns. The regional team also distributed four UHEP implementation tool kits to Humera town. The job-aids will help improve UHE-ps IPC based health service provision. The job aids were distributed with orientation and UHE-ps have started to utilize them at the Kebele level as reference materials. The regional SEUHP team and CO supported TRHB financially and technically to facilitate the printing and distribution of about 9,000 acute watery diarrhea (AWD) leaflets. The leaflets were prepared in Tigrigna language and were distributed to SEUHP towns.

Oromia: In Oromia, orientation was given on FHC utilization for 18 UHE-ps at Bishoftu town. About 200 FHCs were distributed to Jimma and Metu towns. Follow-up and supportive supervision visits were conducted, focusing on the utilization of IEC/BCC materials. The program also focused on addressing gaps observed, during supportive supervision visits, on the utilization of WASH and MNCH job aids that were distributed by the program in FY16. To this end, the regional SEUHP team provided refresher trainings for cluster coordinators during the quarterly regional review meeting. Technical support was also provided to Nekemte, Cheleleki sub-city UHE-ps to provide orientation to WDA leaders on how to utilize the FHC and key health message in the manual.

Follow up and support on the utilization of FHCs and other IEC/BCC materials were conducted as a component of supportive supervision and review meetings. UHE-ps were also provided support on - 36 -

how to use FHCs during Women‘s Development Army trainings and meetings, pregnant mother conferences and model household trainings. During household visits in Shashemene by CCs, more than 75% of the HHs visited were utilizing family health cards and more than 50% of model household attended the training with FHC (more than 100 HHs visited). During household visits using checklists completed by CCs and THO teams, it was found that among more than 100 HHs, about 90%, were model households. They also use FHCs to gain knowledge of key behaviors. On the-job orientation is being provided routinely by cluster coordinators in places where gaps are observed in utilization of FHCs.

2.1.2 Support national campaigns on WASH and HIV In FY17, SEUHP planned to support FMOH and RHBs implement three campaigns: Global Hand Washing, National Wash Movement, and HIV testing catch-up. The program has been working closely with FMOH, RHBs, and other stakeholders including JHU/CCP to harmonize the plan and to collaborate in implementation. So far, SEUHP has been fully engaged in two of the three campaigns, the third campaign, the National Wash Movement was postponed for a later point in the fiscal year. The program supported the following campaigns during the reporting period.

2.1.2.1 Support global hand washing campaign

In this reporting period, SEUHP supported the Global Hand Washing campaign in Amhara, SNNP, Harari, and Oromia. The campaign promoted hand washing among school children. During the campaign, SEUHP and collaborators (e.g., UHE-ps, C/THOs, and education offices in the respective regions) distributed BCC materials and implemented a series of outreach activities in Picture 4: SEUHP supported hand washing day at Addis Amba Primary School, Nifas Silk selected schools. SNNPR Lafto Subcity, Addis Ababa. SEUHP office provided technical and logistical support to RHBs to control a scabies outbreak through the distribution of 5,000 bars of soap, 24,000 brochures, and five jerry cans with a faucet. In Tigray, more than 73,000 leaflets and 6,000 posters focusing on WASH were distributed during the hand washing day. In addition, the SEUHP regional office distributed180 t-shirts and 180 capes with ―Let us make hand washing a habit‖ written in the local language. Similarly, 24,000 IEC/BCC materials with key messages on hand washing were distributed in the Oromia Region.

2.1.2.2 Support WASH movement

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In FY17, the SEUHP Amhara regional office supported AWD-prevention campaigns in Bahir Dar, Debre Markos, and Kombolcha towns in October 2016. Key messages (proper hand washing at critical times, proper latrine management, food hygiene, household water management and safe storage, proper solid and liquid waste management)were disseminated addressing the public at large in collaboration with THO, and communications and mayoral offices. Key messages were communicated to 200,000 people in hot spots and public gathering places. The SNNPR SEUHP regional office also supported the regional Health Bureau to celebrate the Menstrual Hygiene Day (MHD). May 28 is an annual awareness-creating day and a global platform to bring together non-profits, government agencies, the private sector, the media, and individuals to promote Menstrual Hygiene Management (MHM). The RHB, in collaboration with SEUHP and other development partners, celebrated MHD in Hossana town at Bobicho primary school because the school has MHM good practices that can be scaled up to other schools. The event consisted of presentations, a visit to Babicho school, and a brief discussion on MHM. The participants were school directors/school WASH club leaders from two model schools from each town (Arbaminich, Wolayta Sodo, Yirgalem, Butajira and Dilla) and 14 schools in Hosanna town. In addition, different Government WASH sector offices of Hosanna town including the Mayor‘s office participated in the meeting. MHD was celebrated colorfully through a competition among girls focusing on menstrual hygiene, community mobilization using vans, meetings and visits to Bobicho primary school among others.

In addition, SEUHP supported a consultative workshop aimed at developing Acute Watery Diarrhea (AWD) related emergency preparedness tool kit for Addis Ababa. The consultative workshop was organized by Addis Ababa RHB at Bishoftu town on June 7, 2017. The SBCC team conducted a capacity building session aimed at restructuring the RHB‘s approach to designing and implementing SBCC activities relating to AWD. A follow on AWD SBCC campaign planning session was also conducted during the reporting period. In the resulting workshop, Addis Ababa RHB and SEUHP teams identified potential audiences that could have a need for a systematic approach to the SBCC activities.

2.1.2.2 Support National HIV and AIDS Catch up Campaigns SEUHP continues to engage and play an active role in the national and regional social mobilization as a member of the sub-group of the HIV Catch-up Campaign (CUC). As part of this effort to improve the effectiveness of the HIV CUC in achieving desired results at the national level, SEUHP in collaboration with FMOH and UNHCR organized a two-day social mobilization review meeting aimed at evaluating the campaign‘s performance and areas that need improvement to ensure that testing efforts are on target. JSI also presented on its field experience in conducting targeted testing and how this contributes to higher yield. The workshop was organized from June 19–20, 2017 in Bishoftu and was attended by representatives from regions and non-governmental partner organizations including UNHCR, PSI, and Associations of Women Living with HIV/AIDS.

Regional SEUHP teams also provided support to RHBs to implement a series of HIV/AIDS CUC activities that included printing and disseminating different IEC/BCC materials including electronic media products that adapted TV/radio messages on HIV services for MARPs.

In SNNPR the SEUHP team, in collaboration with the RHB, organized a professional material development workshop for the media that aimed to strengthen demand creation activities in relation to the HIV/AIDS CUC by using various audio, audio-visual and print media. The workshop took place from May 19-21, 2017 at Yirgalem. Workshop attendees came from different government sector offices: six participants from South Television and Radio Agency (STRA), four participants from the

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RHB, and one participant from Government Communication Office. Participants included public relation officers, senior reporters, senior editors, clinical officers, and advocacy and social mobilization officers. Following the workshop, a total of five radio spots and two print spots (posters) were finalized and are ready to be tested in the community in FY18.

In order to maximize UHE-ps‘ contribution towards improving adherence to ART, one of the most challenging problems in the HIV/AIDS interventions, SNNPR RHB organized a regional level panel discussion on HIV/AIDS treatment, care, and support activities and related problems. The panel discussion brought representatives of NGO partners, public sector bureaus/offices, religious leaders and others. The main discussion points included the need for collaboration among stakeholders, the declining attention given to HIV/AIDS because of the perception that HIV/AIDS is well addressed and high ART default rate. Accordingly, all participants agreed to revitalize HIV/AIDS service support activities including PLHIV association members gearing effort for tracing defaulters and counseling and support services for PLHIVs to restart treatment. Participants also agreed to develop an action plan to carry out the identified key activities and report their progresses to the RHB regularly.

Amhara regional SEUHP team handed over 34,000 brochures prepared for students, 17,000 for teachers, 10,000 flyers for parents, 830 posters and 50 flyers to the RHB to be distributed in areas where AWD cases were reported. Similarly, the SEUHP Oromia regional team supported C/THOs by providing 5,000 leaflets (2,000 for Nagele, 1,500 leaflets for Woliso and1,500 Robe towns) and 600 posters to increase community-level awareness of AWD-related issues.

Sub IR 2.2. Produce and air radio programs to promote and model key RMNCH, HIV, TB, and WASH-related behaviors

2.2.1 Air radio program to promote key RMNCH, HIV, and WASH behaviors

The radio magazine program promotes facility-based services, healthy behavior and services provided by UHE-ps. The content of the program was designed with findings from the program‘s formative research and a contribution of stakeholders. In the reporting period, 15 episodes were produced focusing on RMNCH, HIV/AIDS, TB and WASH related behaviors. The programs produced were reviewed by a technical working group which included the FMOH‘s and ORHB communication teams and SEUHP team members. The episodes produced were reviewed by a technical working group which included the FMOH and ORHB communication teams and SEUHP team members. The program was aired in Amhara (Malefiya), SNNPR (Malefiya) and Oromia (Dansa) and has continued in Harar, Dire Dawa, and Addis Ababa.

SEUHP also initiated collaboration between its program in Tigray, the RHB and Dimts Woyane (local radio station) to start the production and airing of the radio magazine program in Tigray. This special arrangement was initiated following the RHB‘s request to lead the production of the radio program. By the end of the fourth reporting quarter, the firm has produced 11 episodes and is awaiting approval from the RHB for branding to start airing.

2.2.2 Produce and air serial radio drama

SEUHP developed a 26-episode radio serial drama in three languages. The serial drama aims at promoting healthy behaviors and allows audiences to model behaviors of the transitional characters, who they will follow (through listening) as they struggle and overcome common challenges. The radio serial drama focuses on WASH, RMNCH, HIV and TB and is anchored on behavior model that focuses - 39 -

on modeling. In FY17, the program focused on initiating the production and airing of the radio serial dramas in Amharic speaking SEUHP target cities/towns. SEUHP has finalized the script for 26 episodes. The sub-contractor has produced and submitted the first version for review and feedback. SEUHP team has reviewed the programs and given the feedback and is currently going through a final revision before airing. The program will provide the scripts to Oromia and Tigray RHBs to translate and produce the drama in the preceding period.

2.2.3 Engage media to promote urban health issues in collaboration with FMOH

In recognition of the role of media can play in promoting facility-based services and healthy behaviors, in FY17 SEUHP took the initiative to engage media both locally and at the national level. During this reporting period, SEUHP continued to support media engagement in urban health advocacy by providing guidance in the development of media products and information during content development and follow on activities. The CO team produced a media engagement guide to initiate the activities planned with media outlets. Accordingly, the following activities were carried out by SEUHP at different levels.

Addis Ababa: A two-day media engagement and orientation workshop was organized on March 29-30, 2017 for journalists who came from nine different media institutions (three print and six electronic media). The objective of the workshop was twofold. The first objective was to initiate a structured collaboration platform for the RHB and the media to promote urban health issues. The second objective was to orient participants on key issues associated with urbanization and urban Picture 5: Ato Mulugeta Admasu Head of health issues. A total of 26 individuals Communications at Addis Ababa Regional Health Bureau (11 females and 15 males) attended the participant at Media Engagement workshop that SEUHP workshop. The workshop was organized, August 25-26, 2017, Bishoftu facilitated by technical experts from SEUHP and 8 facilitators from FMOH, “….SEUHP’s media engagement workshop plays a vital Addis Ababa City Administration role in increasing reporting of urban health issues in the Health Bureau (AACAHB) and the media. It showed us the potential media roles in improving AAU–Center for Urban Health and the health of our communities.” covered urban health policy, strategy, existing situations, challenges of urbanization, and the role of media to enhance urban health. Moreover, the UHE-ps presented practical challenges they faced in implementing UHEP. Representatives from each organization developed action plans on how to promote urban health issues. The roles and responsibilities of AARHB and SEUHP in support of these activities were also discussed. Moreover, at the end of the workshop, the media, AARHB and SEUHP agreed to set a regular meeting schedule for the media engagement platform (quarterly) and also discussed a monitoring mechanism to track the implementation of action plans was established.

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In the fourth quarter, the Addis Ababa City Administration Health Bureau in collaboration with the SEUHP Addis Ababa Regional Team organized a media engagement review meeting from August 25-26, 2017 in Bishoftu. The main objective of the review meeting was to follow up on the progress made since their first engagement and update media personnel on urban health. The SEUHP Quality Improvement Officer presented a general overview on the project and summarized activities done so far to acquaint new media outlets that had joined the platform. Media outlets presented what they had accomplished after the previous workshop and planning.

The following are some of the activities that were carried out by media outlets following the media engagement initiative.

Fana FM 98.1  Two programs were produced and aired regarding pulmonary and MDR TB.  Two programs were produced and aired about latrine utilization and environmental health activities of UHE-ps and hygiene and sanitation.

Addis TV and FM 96.3  These media outlets have been very active in addressing the platform agendas since the first workshop. They produced programs, spots, and news about TB, HIV, WASH, and UHEP.

Addis-lisan Magazine  More than five columns were written regarding TB, HIV and UHEP. Picture 6: A column documented by Addis Liaison Reporter, about UHE program.

Ethiopian Herald Magazine  Two columns were published about HIV/AIDS, focusing on PMTCT and the 90-90-90 approach.  One column was published on the UHEP and its reforms.

Addis Zemen Magazine  One column was published on HIV.  AWD and its pre-cautions were published in the latest columns.

Abay FM  One program on TB titled ―TB and the Community‖ was aired. The program discussed ways of transmission and prevention mechanisms. Wrong attitudes of the community about TB were also discussed on the program.

FM 98.1  One program was prepared and aired about HIV.  WASH related health problems and the UHE-ps role was also addressed on a separate program.

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Following these presentations and discussions, priority urban health issues for next reporting quarter were identified - TB/HIV, WASH, and UHEP. Consensus was reached on the need to facilitate tracking of the implementation of the planned media activities and sharing of major public health events by establishing a mailing list which allows everyone to be accessed easily.

SNNPR: Two workshops were organized for media professionals with the aim of strengthening the demand creation activities in relation to the HIV/AIDS catch up campaign by using various audio, audio visual and print media. The first workshop took place at Yirgalem town with the aim of maximizing HIV testing uptake, linkage of those with HIV positive results to treatment and care and ensuring adherence to treatment care and support services using the local media. This will ultimately contribute to the achievement of the three 90 targets for HIV status, access to ART, and suppression of viral load. A total of 21media personnel (15 males and six females) including managers from Fana Broadcasting Corporation (Shashemane and Wolaita Soddo), Ethiopia News Agency (ENA), FM 97.8, South Television and Radio Organization, Government Communication Office, and RHB HIV Prevention control and Multi-sectoral Response Core Process officers attended this advocacy and social mobilization workshop.

The second workshop specifically focused on two major activities: review of performance following the first workshop and developing one TV, one radio, and one print spot in relation with HIV/AIDS catch up campaign which focused to MARPs. A total of 38 media, communications, advocacy and social mobilization professionals (female 40.7%) from various media organizations like South TV and radio, Fanna broadcasting, FM 100.9, Police radio, Government communication team members and regional health bureau representatives attended the workshop. Topics covered in the workshop included the basics of HIV/AIDS, HIV epidemic globally, nationally, regionally and the progression of HIV infection described and discussed. The significance and importance of HIV/AIDS campaigns, progress so far, challenges faced and actions taken were presented by RHB/ HIV/AIDS MSR clinical officer. Presentations by members from various media sectors (South TV and radio, Fanna broad cast, FM 100.9, Police radio and Government Communication) on performances based on their action plan following the first workshop were shared to participants. , From the presentation, it was learned that ten episodes of messages related to the HIV/AIDS catch up campaign were broadcasted, in SNNPR TVs and radio alone, in the form of news, live transmission and health programs following the first media professional‘s workshop

Dire Dawa: The regional SEUHP team held consultative meetings with the RHB on how to use to local media sources (radio and TV) on a weekly basis to cover discussions about the health services provided by UHE-ps and different types of health-seeking behaviors. As part of this effort, the launching of the national HIV catch up campaign and the orientation of UHE-ps, supervisors, CHWs and HIV case managers regarding the catch up campaign was aired through the local TV and radio. Amhara: The SEUHP regional team, in collaboration with the RHB, organized a one-day training (June 3, 2017) for media professionals involving; FBC, Amhara Mass Media Agency (radio, TV, FM & print media), and the Ethiopian News Agency (ENA) for 24 participants (25% female). Topics covered during the media engagement training included the impact of WASH, UHEP, and major WASH interventions. Each team prepared a draft plan and submitted it to the RHB for follow-up purposes. Following the training, Gondar Fanna FM 98.1 addressed topics like AWD (2 times), Trachoma and liquid waste disposal issues through a live discussion. In addition, EDA organized a two-day media professionals training on urban health extension program at Dessie Town and a total of 39 participants (17 female) attended. The participants were sub-city communication professionals, staff from the Communication - 42 -

office, EBC, Dessie 96.0 FM radio professionals and Amhara 87.1 FM radio professionals. A similar two- day training was organized in Debre Birhan town on key urban health issues to media professionals. There were 34 participants (11 female). The overall purpose of the training was to enable media awareness of urban health issues and closely work with the health sector on continuous basis.

Tigray: The regional SEUHP team, in collaboration with the RHB, organized training for 25 media personnel and four RHB staff from June 24-25, 2017 at Wukro town. The main topics covered during the training included national strategies and priorities, urbanization, status of the urban health program, HIV and WASH. Accordingly, a memorandum of understanding (MOU) was signed between the SEUHP regional office and Dimtsi Weyane for the production and airing of a radio magazine program on urban health. Oromia: A two-day workshop was organized from August 1-2, 2017 for media professionals in Bishoftu town, in collaboration with Oromia RHB. The overall goal was to improve the level of collaboration between media outlets and the health system structure at the regional and city/town level with the aim of increasing coverage on selected urban health related agendas. In this workshop a total of 25 individuals from different media outlets such as Oromia Radio & Television Organization, Fana Broadcasting Corporate, FM of Shashemene, Nekemte & Asella, Bakalcha & Oromia from printed media, 6 educational radio stations in Oromia and RHB staff who worked on communication attended the workshop.

Six presentations that aimed at increasing the media‘s level of awareness on the current Ethiopia and Regional urban health related problems were presented. After group discussion on the role of media in addressing the existing urban health challenges, participants developed a six-month plan that aimed at promoting urban WASH issues to the public agenda, working on HIV awareness creation and RMNCH related issues. In FY18 SEUHP will provide support to the RHB and media outlets in producing the planned media activities. 2.2.4 Produce and air song to create high-level social mobilization on WASH

One of the major challenges of urban WASH is the community‘s attitude towards personal and environmental hygiene. In FY17, SEUHP planned to contract celebrities to produce songs in three different languages (Amharic, Oromiffa, and Tigrigna). As part of this initiative, SEUHP hired two local artists to produce one WASH-focused song and a video clip. These two communication materials were produced in Amharic and were presented at the first national Urban Health Conference and targeted higher level leadership. The materials were well-received by participants and the media.

Sub IR 2.3: Enhance RHB and C/THO SBCC programming capacity

During the reporting period, SEUHP planned to conduct two rounds of capacity building trainings targeting C/THO program team focusing on strategic SBCC and community mobilization. To this end the team adopted a strategic health communication field manual developed by JHU/CCP and also developed a training manual for community mobilization. SEUHP was also actively engaged in the drafting of the national SBCC quality assurance guideline and SBCC module of the in-service training material currently under development to train extension workers for school health program. SEUHP and JHU/CCP co-facilitated the TOT program organized by the FMOH. The training targeted RHB representatives and was attended by 30 participants. The collaboration between SEUHP and JHU/CCP to customize/develop and co-facilitate training modules for training other government staff has continued. - 43 -

PART 1.3: STRENGTHEN REGIONAL PLATFORMS FOR IMPROVED IMPLEMENTATION OF THE NATIONAL URBAN HEALTH STRATEGY (IR 3)

To strengthen UHEP implementation at RHBs/ZHDs, and C/THOs, the SEUHP team has been providing technical support with the aim of institutionalizing supportive supervision and review meetings for sustainable program improvement. SEUHP has also been working with C/THOs and partners to improve their organizational capacity and leadership in implementing UHEP, and provide TA to fill gaps identified through periodic need assessments.

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Sub IR 3.1: Improve institutional and managerial capacity of urban health units at RHBs, ZHDs, C/THOs

3.1.1 Provide technical support to RHB, ZHD, C/THO, HC staff to develop work plan based on the revised UHEP Implementation Manual

In FY17, priority was placed on ensuring ownership of the Urban Health Extension Program (UHEP) at different levels, building the capacity of HC and C/THO staff to coach UHE-ps on skill gaps, supporting them to use information for decision making and planning, and generating more evidence in urban health issues. To ensure ownership and sustainability of the urban health programs as part of its health system strengthening support, SEUHP teams have been working closely with RHBs, ZHDs, and C/THOs in planning and implementation of the UHEP. The SEUHP team supported Kebeles in the development of the Ethiopian Fiscal Year (EFY) 2009 plan through the involvement of the UHE-ps. Hence, UHE-p annual plans, particularly in Amhara, Oromia, and Harari regions and Addis Ababa, capture all services they are expected to deliver, per the standards indicated in the revised UHEP implementation manual. In Harar, the regional SEUHP team provided technical support to the RHB during the development of UHE-p annual planning of the 2009 EFY based on the review of the 2008 EFY achievements at baseline. Currently, many UHE-ps have their own 2009 EFY annual plans and have updated catchment population profiles in their respective kebeles. UHE-ps received technical support and guidance on setting targets and monitoring indicators for the 2009 EFY, and the team has made an effort to align the SEUHP plan with that of the government at all levels.

SNNPR‘s SEUHP team provided financial and technical support to Hawassa City Administration for development of a Woreda-based plan for the 2010 EFY through the involvement of UHE-ps. Activities of UHE-ps were captured per the standards indicated in the revised UHEP implementation manual. As a result, each UHE-p has updated the catchment‘s annual work plan and the respective catchment population profile.

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3.1.2 Conduct leadership, management, and governance capacity enhancement for RHB, ZHD, C/THO, and HC staff

The leadership, management, and governance (LMG) training aims to enable urban health leaders to identify and fill gaps that have hindered effective implementation of UHEP. The leadership management training is designed for health care providers and health workers, and is believed to improve the work climate, management systems, and individual responsiveness to change and delivery of high- quality health services in an Picture 7: H.E. Dr. Kebede Worku, State Minister for Ministry of Health visited LMG equitable manner to implementation at Woreda 10 health center staff and appreciated the staff motivation ultimately improve health and the changes brought as the result of the LMG training. outcomes. LMG training consists of four rounds over six months, with each session lasting for two to three days. The first round deals with acquiring knowledge and skills on how to develop a mission vision, and measurable results; the second focuses on skills and knowledge to develop indicators, prioritize activities, and develop action plans. In the third round, trainees present their completed challenge model with progress results; and in the fourth round HC performances are evaluated against the defined indicators.

In FY17, SEUHP operational regions have been doing much to build on the LMG capacity building initiative. Though the LMG training manual notes that HCs or C/THOs are not expected to show major changes until the third round of the training, some regions have shown improvements in the challenges they identified at their health centers after the first round of training. The training has cultivated motivation, good team spirit, and coordination within most of the health centers towards addressing the identified challenges. Some of the accomplishments are briefly explained as follows:

Amhara: All the four rounds of the LMG training were rolled out at Han HC in Bahir Dar and Debre Markos HC in Debre Markos town in collaboration with the respective health offices and health centers. Thus, a total of 24 (14 females) and 27 (14 females) participated in the training at Bahir Dar and Debre Markos towns, respectively. The coaches from SEUHP observed that the training highly motivated the team and engaged them in additional activities related to the challenges they identified by the end of each training session.

The major change objectives identified during this round include: provide supplies and reduce out of stock prescriptions; enhance the screening of adult outpatient department (OPD) clients for hypertension which was none at baseline; increase health care services by availing essential drugs to all

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HCs in Bahir Dar, increase TB case detection rate of Debre Markos HC; and increase HBHTC of Debre Markos HC. Targets were set for each indicator with due dates. The Facilitators were from Bahir Dar University, Bahir Dar Health Science College who received the LMG training by the USAID LMG project and the RHB facilitated the cascading to the respective towns.

The major changes observed after the respective LMG trainings and identification of change objectives include:

 The team was able to achieve a nearly zero outgoing referrals for drugs through replacing out-of-stock drugs on time and through purchasing the drugs that are not availed by Pharmaceutical Fund Supply Agency (PFSA) from private drug suppliers in consultation with the management team.  The Outpatient Department (OPD) team decided to screen all clients aged 15 years and above for hypertension. In the last six months, about 2,430 OPD patients were screened for hypertension. The team is committed to make this practice part of the routine activities at the HC and also have included ‗healthy life styles‘ as part of the weekly health education schedule for clients.  The patient card filing system is computerized. In case of power interruption, the team in the registrar is able to use the alphabetically arranged card filing. This was done by recognizing the poor documentation and filing system of the HC and by training four individual clerks that work on filing including the basics of computer  In the absence of such a filing system and because of repeated misplacement or loss of client cards, the quality of services provided by the HC was affected due to: long waiting time for patients while clerks are looking for lost cards, resource wastage for issuing new card, not being able to get the past history of the client during diagnoses and treatment, complain and argument between the clients and care providers. Besides, the HC team had to merge three rooms to avail a bigger card room with bigger window with better air circulation. Similar arrangements were made for the laboratory unit. Such a change following the LMG training has created a good working condition in the HC.  The introduction of Smart Care Services in the card room enabled the Bahir Dar Health Center card room workers to easily pick client cards which contributed a lot in reducing waiting time which has a known effect in client satisfaction. The HC was also able to monitor its supply system regularly and significantly reduced the shortage of essential drugs and avail to patients/clients.  Debre Markos HC attributes the increase in TB detection rate, increment of long term use of family planning methods to the implementation of LMG as it created commitment, staff motivation, and coordination among the team.  The team also conducted a work climate assessment and was able to solve the misunderstanding between the administration and technical team.

SNNP: The LMG training is the first of its kind for SEUHP SNNPR including the health centers and the town health offices. The first round training took place between November and December 2016 at Hawassa and Sodo for Alamura and Dodo HCs and Sodo THO staff respectively. A total of 74 participants (46 female) attended the training in the two sessions. The training sessions were conducted in collaboration with Hawassa City Administration Health Department, Hawassa University, Dilla University and Wolaita Sodo University. After the first round LMG training, two rounds of coaching and mentoring visit were carried out in Alamura health center, Sodo health center and Sodo - 47 -

town health office. Some of the progresses made include: all teams started documentation and keeping of information in separately labeled folder for their respective teams, the challenge model of the team was almost completed, and the desired measurable results of all teams were clearly stated.

By the end of FY17, all the three LMG sites in SNNPR received the third round training. But, due to different competing activities of the government, the planned fourth round training was postponed to take place in 1st quarter of FY18. The 3rd round LMG workshop was carried out for the three sites from September 15-17, 2017 for Soddo health center staff in Soddo, for Alamura health center staff from September 20-22, 2017 in Hawassa and for Soddo town Health office staff from September 28- 30, 2017 in Wolaita Soddo town. The workshop was facilitated by trainers from Dilla University and Wolayita Soddo University, who are rich in experience and hold their second degree in health care management. The SEUHP regional team (Hawassa and Soddo CCs and RPHA) were actively involved in organizing the workshops.

The training topics covered during the training sessions include health facility resources management; like human resources, health information, time management and management of physical structure, health care financing and financial management, Supply Chain Management, concept and model of managing health service delivery, continuous quality improvement and effective referral linkages. Participants also witnessed that all the covered topics are very relevant for the workforce to apply it in their respective health center, in order to improve performance, increase health service uptake and improve performance quality.

The major achievements of the team at Alamura health center following LMG training were:

 Emergency OPD waiting time reduced from 40 minutes to 15 minutes,  Referral with feedback increased from 40% to 68%,  Drug availability increased from 80% to 94% and  Transitioning HMIS from manual to electronic system increased from 50% to 80%.  Team spirit also improved, staff ownership became strong and every team member is motivated and committed to accomplishing activities.

Tigray: A total of 79 staff members (50 female) including 37 HC staff and 42 THO staff from Mekelle (Semien health center) and Aksum (Millennium health center), attended the first round of LMG training. The team identified some indicators that need improvement and showed remarkable achievement from the start. For example, to increase completed referrals from 20% to 42%; awareness-raising activities were performed for all HC technical staff on the importance of documenting and sending referral feedback to UHE-ps. SEUHP provided an orientation on the service data recording tool (SDRT) for case team leaders, sub city cluster coordinators, experts, and UHE-p supervisors and follow-ups were made on the proper use of referral boxes and on timely collection and submission of feedback to all UHE-ps through their supervisors, by all staff.

Addis Ababa: The regional team, in collaboration with AACARHB and UASID funded LMG project, facilitated last (fourth) round of LMG training for each LMG sites whereby 96 (54 females) from four health centers in Nifassilk Lafto, Kolfe, Arada and Yeka sub-city. Accordingly, coaching and follow-up visits were conducted in each HC. Results of follow-up visits showed that all of the trainees discussed and refined their mission, vision and measurable results and they were able to implement the plan of actions developed during the training.

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Changes observed following LMG training include:

 The training has created motivation and team spirit among staff of the HCs which has encouraged the health office teams to go to health centers and visit, do assessment, discuss and learn some of the basic needs needed by the health centers.  Because of the sense of accountability and motivation ignited by the LMG, the MNCH team of Woreda 6 HC (Yeka) facilitated a community health education session about institutional delivery as this was the priority identified during the training. The team is also working on improving the service quality for ANC, Delivery and Postnatal care services. The works done to improve the service included; updating registration roster of the pregnant mothers by UHE- ps, listing out or identifying mothers who defaulted from ANC follow-up and requested additional new delivery coaches from AACAHB to improve quality of delivery service.  The management team of Woreda 10 HC (Yeka Sub City) prioritized to address power interruption challenge of the HC. The team discussed and reached on consensus with the sub- city health office and succeeded on purchasing the generator after passing all the bureaucracy at different levels. Now, the health center has a generator that can supply power for 24 hours.  To increase the ANC4 visit coverage from 40% to 78%, the team performed the following activities.  The team had a discussion session with all UHE-ps to strengthen defaulter tracing of ANC mothers.  The MNCH team developed an appointment calendar for ANC clients and close follow-up was made during their appointment days. If clients do not appear on the days of their appointments, messages are passed to the UHE-ps for them to remind or trace clients.  An internal referral system was established with Woreda 5 HC to provide ultrasound services for those clients who cannot afford to get the service from private diagnostic centers.  The laboratory team learned that one of the causes for ANC defaulter was unavailability of laboratory reagents, as some mothers can‘t afford to access private health institutions, the management team of the HC decided to purchase lab reagents from other suppliers instead of waiting for Pharmaceutical Fund and Supply Agency (PFSA) to provide the reagents.  The finance and procurement team of the HC worked on how to shorten the long procurement process to speed-up procurement of drugs and supplies.  To facilitate the transfer of leadership knowledge and skill, an experience sharing visit was organized at Wereda 10 (Nefasilk sub city) for FMOH, AACAHB, SCHO and SEUHP staffs. On this visit, the HC team presented activities and major achievements (indicated above) of the post-LMG training implementations. The major challenge that was raised during the site visit was a shortage of medical supplies and equipment to improve the health service delivery. Based on the raised gaps, SEUHP provided an ultrasound machine in order to improve quality of maternal health care and to enhance referrals by UHE-ps.

Dire Dawa: finalized preparatory activities including selection of health centers and trained regional SEUHP team on LMG in the first quarter of FY17. The second round of the LMG training was also organized for Dechatu Health Center attended by 24 participants (11 female).

Harar: The SEUHP team in Harar facilitated the cascading of LMG training by first providing a one- day orientation for the senior level officials for the selected two health center case teams and in one woreda health office as well as RHB experts to equip the health professionals with the managerial, leadership and governance skill. A total of 44 individuals (24 female) attended the three day training workshop held from July 6-9, 2017. By the end of the training workshop, participants developed their organizational challenge model and identified at least one challenge per their organization with a detail action plan that included a monitoring and evaluation system.

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Oromia: In the second quarter of FY17 a senior alignment meeting was organized for two towns that are engaged in LMG exercise. The senior alignment meeting was aimed at orienting managers and respective town level decision makers about the essence of the LMG, so that the management team could provide the required support and commitment for the implementation of the LMG activities. A total of 25 individuals (11 from Adama and 14 from Shashemene towns) attended the half day alignment workshop hosted at both towns. The participants included; the town health office head, deputy town health office head, respective health centers head, case team leaders & UHEP coordinators. Respective Picture 8: (Left) Semira Mohammed, PHCU Director, Biftu Health Center town‘s health office head receiving the LMG training completion certificate. showed their interest in implementing the LMG and She said“…I never knew that we have such potential to deliver.LMG equipped us promised to provide on the managerial skills that we need in our everyday work. The team spirit and necessary support for the commitment has greatly improved leading us to better service provision quality at success of the initiative. The our health center.” first round of LMG training was rolled out for selected health centers of Adama (Biftu HC) and Shashemene (Abosto HC). A total of 48 participants (32 female) attended the three days training at the respective towns. The participants were pulled from different case teams of the health centers.

A total of 63 individuals (32 female) attended the fourth round of LMG training for two days at Adama and Shashemene towns. As it was last round of the LMG session the workshop was organized for the presentation of results and the identification of additional measurable results.

Major achievements reported at Biftu Health Center included:  Good team spirit, increased motivation, improved communication and working relationships among staff and with the THO feeling like a leader.  Improved referral and linkage between HC and UHE-ps.  Positive feedback on service satisfaction were also observed;  When the LMG training was started (March 2017), on average about 881 clients/patients visited Biftu health center while the ANC 4 coverage was 46%. By the end of the third round of LMG workshop, (August 2017) about 1626 patients received service from OPD and the ANC 4 coverage reached 81%. UHE-ps played significant role in increasing ANC4 coverage through referral and tracing those who dropped out from service after ANC1 visit.

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Major achievements reported at Abosto Health Center between March and August 2017 includes:  FP coverage increased from 39 to 55% (target = 65%)  ART defaulters decreased from 10% to 3% (Target = 5%)  60% patient/client data entered into computer (from client card) (Target = 52%)  HIV testing increased from 29% to 60% (Target = 65%)

To bring the aforementioned achievements at LMG sites, different interventions were implemented. The team at Biftu health center availed necessary drugs, recruited additional human resources, separated under-5 OPD from adult OPD, constructed a fence and a standard incinerator in collaboration with THO which made the compound more attractive; constructed hand washing facilities near the toilets at health center and hand washing sinks prepared at seven different rooms.

Similarly, Abosto health center of Shashemene painted windows of all medical units to ensure privacy of the client, recruited additional human resources (2 health officers, one midwifery and one clinical nurse) for the health center, accelerated automation of patient cards, reviewed ART files and identified lost clients, traced lost clients from ART, did awareness creation activities on long acting FP, established separate FP unit, linked clients from EPI and PNC to the FP unit, enhanced targeted HTC and availed one extra OPD unit.

3.1.3 Build Institutional Capacity of FMOH to Deliver High-Quality Service

SEUHP has been providing support to strengthen the institutional and technical capacity of the FMOH to deliver high-quality health care services through the development of competency-based training materials and capacity-building trainings, guidelines, job aids, etc. In this regard, 11 senior technical assistants were hired for different durations in FY17to provide support to the ministry. The TAs have been instrumental in the follow-up and support of the implementation of the health sector transformation agendas while providing technical support to Office of State Minister and four directorates of the FMOH: Clinical Service, Health Service Quality and Emergency and Clinical Care directorates.

Some of the activities implemented by the TAs are;

 Developed roadmap for the training of health workers.  Reviewed guidelines for Dress Code of health professionals and medical missions.  Conducted supportive supervision to health facilities in the different regions to provide onsite support.  Reviewed health sector transformation document.  Developed document on the basic mannequins and equipment list for hospital maternal and newborn health skill labs with relevant references.  Reviewed home-based care intervention projects for household/bedridden and disabled patients.  Developed a symptom-based diagnostic algorithm that can be used as a reference in the primary health care setting.  Prepared reference documents on Disaster Medical Assistance Team (DMAT).  Reviewed quarterly bulletins published by FMOH.  Developed the M&E framework for Saving Lives through Safe Surgery (SaLTS).

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 Developed SaLTS mentorship guide, training materials and modules and conducted SaLTS training.  Reviewed and adapted the second batch of the practical algorithm approach to care kit (PACK).  Prepared a trauma system protocol.  Drafted a clinical governance document.  Developed supportive supervision checklist on Ethiopian Hospitals Service Guidelines (EHSTG), Health Sector Transformation in Quality (HSTQ) & QI implementation for 39 lead hospitals of the country.  Organized a one-day symposium on Road Traffic Accident (RTA) prevention and on how to improve the post-crash responses services prepared by FMOH.  Conducted training on emergency and critical care.  Conducted a survey on challenges of Addis Ababa city pre-hospital care.  Finalized localization of Ethiopian Primary Health Care Clinical guidelines  Reviewed first aid trainees & instructors manual.

3.1.4 Conducted coaching skill training for HC technical staff and UHEP officers

Coaching training was organized for HC technical staff and UHE-ps supervisors for three days in Amhara, SNNPR, Oromia, and Tigray regions. The objective of the training was to enhance the competency of Health Center technical staff that is responsible to coach urban health professionals at office and in the community. The training enhances the skill, knowledge and attitudes of health professionals in order to carry out knowledge based, appropriate, and fruitful coaching/mentoring practice which is capable of improving performance of UHE-ps so as to increase service uptake and quality of services. A total of 439 (230 Females) participants attended the coaching skills training from 14 towns: Bahir Dar, Debre Markos, Gondar, Dessie, Hawassa, Hosanna, Butajirra, Arbaminch, Wolaita Soddo, Jimma, Aksum, Adigrat, Mekelle and Alamata. Post-training follow up visits were also conducted in some of the health centers and it was found out that those trainees cascaded the training to their colleagues. Such practice is expected to facilitate skill and knowledge transfer among staff.

Table 5: Summary of coaching skills training participants, Oct. 2016-Sept. 2017

Sex of participant

Region Male Female Total 23 9 32 SNNPR 9 16 25 Oromia 66 59 125 Amhara 111 146 257 Tigray

Total 209 230 439

3.1.5 Conduct joint supportive supervision in collaboration with FMOH and RHBs

SEUHP has been facilitating joint supportive supervisions in collaboration with RHBs in SEUHP- supported regions to improve quality of UHEP service provision and strengthen links and interaction between the community and health facilities, including referrals. The JSS creates better opportunities - 52 -

for the RHB staff to understand how SEUHP support is contributing to improving the quality of UHEP implementation at different levels.

In FY17, SEUHP has supported the national bi-annual joint supportive supervision (JSS) coordinated by FMOH to improve quality of overall health system, the health service provision and to assess links between the community and health facility. SEUHP contributed three experts (AA Public Health Advisor, MER Advisor, and Tigray Regional Manager) to be part of JSS teams in Tigray region, and Dire Dawa and Addis Ababa city administrations. The joint supportive supervision (JSS) was conducted from March 14-28, 2017 with the objective of:

 Collecting information on UHEP‘s implementation status, major achievements and its challenges.  Understanding how SEUHP is supporting and contributing to improve the quality of the UHEP implementation at different levels; and  Strengthening the collaboration between FMOH and RHB.

The supportive supervision was facilitated using SS checklist prepared by FMOH. Overall, three RHBs, three Hospitals, seven HCs, eight health posts, and two households were visited. On-spot feedback was provided for the respective RHBs and sites visited based on the gaps identified. A written trip report was submitted to the RHBs in the presence of FMOH‘s State Minister, State Minister Advisor, RHB Heads, and SMT members of RHB.

In addition to national-level JSSs, SEUHP has been facilitating JSS in collaboration with RHBs in SEUHP-supported regions to improve quality of UHEP service provision and strengthen links and interaction between the community and health facility, including referrals. The JSS creates good opportunities for the RHB staff to understand how the support of SEUHP is contributing for improving the quality of UHEP implementation at different levels. In this reporting quarter, SEUHP regional teams facilitated similar JSSs in collaboration with RHBs. JSSs were conducted in Amhara, SNNP, Dire Dawa Administration, Oromia, Tigray, Harar, and Addis Ababa city administration. RHB HEP coordinators, Regional DPHP core process owners, Regional SEUHP representatives, ZHD HEP officers, THO HEP officers, HC head, and UHE-ps supervisors participated in the JSS, though the team composition varies between regions. The team visited sample households, UHE-ps, UHE focal persons, and THOs among others. A total of 44 towns and 1,177 UHE-ps received the visit. The team used standard checklist to carry out the supervision and gave written feedback to the supervisees. The SNNPR SEUHP team in collaboration with Hawassa city health department multi-sectorial HIV/AIDS response core process, also conducted JSS for the ongoing HIV Catch up Campaign.

Some of the major changes observed during the JSS visits include:

• There are improvements in the level of awareness of household members about FP, utilization of sanitation facilities, solid and liquid waste management, ANC follow up, EPI, TB suspect identification which may indicate the contribution of UHE-ps. • There are remarkable efforts and contributions by the health development army for the better implementation of the UHEP. For instance; in Debre Birhan Town the HDAs do manage solid waste by providing dust bins for their surroundings, working on urban agriculture with the objective of improving nutrition. • UHE-ps have updated kebele population profiles and individual level annual and quarterly plans, and performance monitoring charts.

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• UHE-ps in most regions have updated Kebele level minimum standard wall charts and posted, for example: population profile, Kebele map and quarterly performance monitoring charts. • Most UHE-ps recorded and documented the follow up of pregnant mothers and children under 1 for ANC and vaccination respectively. PLHIV data was also available for care and support services and to provide HTC services for their family members. • UHE-ps are recording and documenting the follow up of pregnant mothers and children under 1 for FANC and vaccination respectively. PLHIV data was also available for care and support services and provision of HTC services for their family members. • Good collaboration with PLHIV associations in HCT target identification and home-based care and support is observed in some places like Sechdu Kebele in Hosanna town of SNNPR. • The implementation of the revised UHEP manual has also encouragingly improved although HCs and Kebeles are at different status. • In many towns, following cascading of the revised implementation manual, UHE-ps are directly supervised and managed by health centers and their accountability shifted from Kebele administrators to health centersr. This has improved UHE-ps‘ performances. • UHE-ps witnessed that frequent technical support received from health center staff and working together with them increased their confidence, and created an opportunity to improve their skills in provision of HIV testing, conducting PNC and provision of RH/FP services. They are also able to get the necessary supplies from HCs. • UHE-ps started providing contraceptives, Vitamin-A supplementation and deworming services at UHE-ps unit. • Because of the strong linkage with HC staff, UHE-ps are getting technical support from health center staff and this has increased their confidence and created an opportunity to improve their skills in the provision of HIV testing, PNC and other RH/FP services. They are also able to get the necessary supplies from HCs. • Some UHE-ps are performing school WASH activities based on the 15 packages outlined in the UHEP.

There were also major gaps identified during the JSSs:

• There should be situations that would allow UHE-ps to provide postnatal care services beyond health education. • UHE-ps should improve the poor utilization of job aids, poor school health interventions, low referrals and complete referrals, poor recording and documentation of services, and gaps in follow up of plans against performances. • Despite their huge contribution in WASH activities, community TB referrals, defaulter tracings, lost to follow up and MNCH services, they should be further capacitated through basic and refresher trainings. • The administrative procedures including the time taken to travel (in the absence of means of transportation) to sign timesheet at HCs and going back to Kebeles to pick supplies and go for HH visits are very tiresome for UHE-ps and is making them inefficient. • Appropriate tools should be availed and orientation should be given to UHE-ps for the categorization of households to prioritize for service delivery. • Targeted HTC service need to improve. • Many of the UHE-Ps are recording only health education as direct service and referral feedback information is not updated in timely manner. • Some UHE-ps need to improve receiving and documenting referral feedback properly and the use of referral and defaulter tracing registrations. - 54 -

• There should be consistent and standardized planning of UHEP activities across sub-cities. • Supervisors should practice the use of checklists during supportive supervision.

3.1.5 Conducted supportive supervision for UHE-ps and UHE-p supervisors

In FY17, SEUHP has been providing technical support to C/THOs to conduct continuous SS and coaching visits to UHE- ps. This contributed to the improvement of UHE-p capacity to deliver quality services. In this reporting period, SEUHP has been providing technical support to C/THOs and HCs to conduct regular SS to UHE-ps to improve the quality of UHEP implementation and overall documentation both at C/THO, HC, and kebele/woreda levels. The methods of the supportive supervision include; interviews guided by checklists, document review (plan and report, and different registers), and the provision of onsite feedback to the supervisees.

During supervision, the team reviewed the performance of UHE-ps and supervisors, the linkage between UHEP and HCs, the quality of services provided by UHE-ps, the quality of data collected by UHE-ps, the functionality of referral systems, health development army involvement in health promotion activities, and the support they are getting from UHE-ps, adherence to the set standards of practice in making referrals and linkages to health services; establishing rapport with beneficiaries and assessing needs; supply systems, the proper use of the service data recording tool; and reporting. The team also provided technical assistance and onsite coaching to UHE-ps based on identified gaps and developed joint action plans to improve implementation, and made follow-up visits to ensure the implementation of action points. Supportive supervision findings are being communicated and discussed with HC heads and supervisors. A total of 2482 UHE-ps, 315 UHE-ps (609 UHE-ps and 69 UHE-p supervisors for Q4) supervisors received supportive supervisions in collaboration with HC and THO in Amhara, SNNP, Tigray, Harari, Dire Dawa, Oromia, and Addis Ababa. During the SS, the following positive findings were observed: • Challenges with regard to referral, linkage and defaulter tracing are reduced due to regular meetings and discussions, supportive supervision, review meetings and orientations. Weekly feedback collection mechanisms are also in place in many places between HCs and UHE-ps and supervisors. • Targeted HTC service provision and its yield are progressing well. • UHE-ps in many SEUHP operational towns are using the standard service recording tool for the services they provide. The completeness, accuracy and consistency of the data are very much improved. Thus, data quality improvement is one of the achievements at the UHE-ps‘ level. They are also using SDRTs as their source of data for reporting. • Referral services are improving. UHE-ps are identifying clients who are eligible and referring them to the facilities for different services. However, the referral feedback requires more effort to be improved. • Standard wall charts are updated and posted on the wall of the UHE-ps office. • Direct services are diversified and its quality is improving because of supplies, equipment and trainings are now available. • UHE-p supervisors are conducting regular supportive supervision based on the knowledge and skills gained from SS training and the SS trained C/THOs staff have been conducting SS as a team at the town level UHEP quarter review meetings and present their SS findings in the meetings.

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• Some QI teams like the ones from in Debre Markos helped UHE-ps in strengthening documentation, data quality improvement and reporting (sample record data checks, use of data for comparing performance made and Lot Quality Assurance System (LQAS) is in place). • Supplies are refilled using supply management systems and monitored by pharmacists monthly and provided monthly feedbacks (e.g., Bahir Dar, Kemissie, Debre Markos, Finote Selam). • Findings from the household visits done during supervision showed good understanding on the benefits of waste disposal, Maternal, Neonatal, and Child Health. • Established condom outlets were found to be functional in some towns. • UHE-ps incorporated School Health activities in their annual plan.

Areas that need improvement include:

• In most Kebeles, UHE-ps didn‘t prioritize service users as recommended in the revised UHEP implementation manual. • There are occasions where some UHE-ps do not record services they provide and are under- reported. • Poor recording and reporting of some WASH indicators. • Poor utilization of lliquid waste disposal sites and hand washing facilities were observed during HH visits. • Household categorization according to the revised UHEP implementation manual still needs further support though there is a good start. • Documentation of complete referrals still needs improvement. • Proper use of job aids and educational materials by UHE-ps still needs improvement. • Poor utilization and documentation of group service data recording and reporting tools and model family follow-up checklists. • Poor coordination at the Kebele level, particularly with offices on Sanitation and greenery issues. • Poor utilization of job aids. • There is still gap in providing direct services by UHE-ps as per the revised Implementation Manual. Most of their activities are providing health education. • Supplies such as dip-sticks, iron foliate, Paracetamol and emergency kits are not available through the revised implementation manual is being implemented.

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Table 6: Individuals Who Received Supportive Supervision by Region, Oct. 2016-Sept. 2017

Total FY17 FY17 Q4

Region Total Total UHE-p UHE-p UHE-ps UHE-ps supervisors supervisors

Addis 53 8 61 695 185 880 Ababa Amhara 235 28 263 326 34 360 Harar 0 0 0 74 6 80 Oromia 18 18 426 35 461 Tigray 191 21 212 213 15 228 SNNPR 12 2 14 334 38 372 Dire Dawa 31 10 41 99 2 101 Total 540 69 609 2167 315 2482

3.1.6 Provide technical and logistics support for regional and city/town level program review meetings

In FY17, SEUHP provided technical and logistical support to the Contribution of monthly RHBs and C/THOs by conducting program review meetings to supervisors meetings assess program implementation. Regional and town level quarterly The regular monthly supervisors review meetings received support from the respective SEUHP meeting showed promising regional offices in all SEHP-supported regions. More than 4111 results in increasing utilization participants, including THO staff, UHE-ps, UHE-p supervisors, and service data recording tools HC staff participated. Of all, 1667 of them were participants of (SDRT) and referral slips the fourth quarter review meetings. Major topics discussed contributing to improved during the review meetings included: monitoring the performance performance in SEUHP‘s PMP of UHE-ps, quality of UHE-ps‘ services, targeting indicators; standardized the homeless/vulnerable populations, application of the UHEP manual implementation of the program (Focal person, Supplies, equipment, assigning HC staff to UHE-ps, across sub cities/woredas; regular Review meeting), capacity building to HC staff, Motivation improved data quality and of UHE-ps, sectoral collaboration (WASH platform and TWG), timeliness of reports; facilitated scale up of models and experiences, documentation, recording, experience sharing among sub- reporting and data quality, referral services and feedback, cities and woredas, and defaulter tracing, documentation and utilization of SDRT as a improved achievements due to source document during reporting, number of individual reached positive competition and by UHE-ps, growth monitoring, nutritional screening and learnings created. This may be counseling activities, strengthening community mobilization to replicated in other regions with create home delivery free communities, provision of FP services, minimal cost of meetings to condom distribution, and NCD screening, HC weekly support to UHE-ps, integration of services during campaigns, and ensure government ownership. strengthening the support provided to UHE-ps by their supervisors.

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In addition, Addis Ababa, Amhara, Tigray, and Oromia SEUHP teams organized Monthly Supervisors‘ Meetings with the active participation of UHE-ps supervisors, HPDP core process leaders, Woreda health office and sub-city UHEP officers.

One of the encouraging performances from Oromia region was that two review meetings were carried out with cost-sharing from THO (Jimma and Adama towns). The THO at Adama covered cost of local transportation allowance while the THO of Jimma town covered hall rent. This would facilitate the institutionalization SEUHP efforts towards the end of its implementation period which will be capitalized more in FY18.

Generally, the regional and town level review meetings were helpful in identifying challenges; celebrating successes; and creating common understandings among the stakeholders on the implementation of Urban Health Program.

Table 7: Regional and town level review meeting participants by region, Oct. 2016-Sept. 2017

FY17 Q4 FY17 Total HC THO UHE- HC THO Region UHE-ps Others Total Others Total staffs staffs ps staffs staffs Amhara 118 193 117 88 516 118 193 100 67 478

SNNPR 72 81 14 42 209 395 384 149 201 1,129

Tigray 17 4 14 19 54 194 68 162 15 439 Oromia 159 108 96 74 437 722 295 279 230 1,526

Addis Ababa 0 18 94 81 256 0 81 94 81 256

Dire Dawa 58 34 19 18 129 58 34 19 18 129 Harar 20 8 16 22 66 60 17 31 46 154 444 509 370 344 1,667 1,489 1,038 815 640 4,111 Total

3.1.7 Conduct urban health system strengthening training for high-level policymakers and managers at FMOH and RHBs by organizing an educational trip to Thailand

In FY17 SEUHP planned to organize structured learning visit with the aim of facilitating of learning on PHC and WASH to galvanize in-country efforts by hosting individuals from government health systems and stakeholders from other countries and to translate learning to action through targeted post-visit follow-up. Hence, SEUHP team in collaboration with Harvard School of Public Health travelled to Thailand to organize site visit for the delegation to be formed from; FMOH, agencies, regional health bureaus, USAID, Harvard School of Public Health, and SEUHP. The delegation is expected to be led by State Minister Dr. Kebede Worku and the plan is to conduct the learning trip in Thailand from October 30 to November 3, 2017.

3.1.8 Conduct regular SEUHP internal program progress review meeting

SEUHP conducted regular project progress review meetings at regional and national levels. The following were the major discussion points during the progress review meetings held in the current reporting period: - 58 -

 How to improve job aid utilization and proper use of equipment like BP apparatuses.  Improving identified performance gaps identified during supportive supervisions and review meetings.  Strengthening school health services.  Implementation of the revised UHEP manual at all levels of the health care system.  Targeted HTC and improving the yield.  Strengthening the QII and understanding the measurement of QI results.  Implementation of the action plan following the first round of the internal Data Quality Assessment (DQA) findings.  Follow up on the construction of emergency WASH.  Continuing the support on AWD outbreak response.  Continuous coaching of UHE-ps by health center staff and supervisors.  Strengthening the involvement and participation of different sectors and making UHEP a discussion agenda at all levels.  Working on overall performance improvement, and strengthening the PHCU networking.  Follow-up of action points identified during the national urban health conference.

3.1.9 Organize national urban health conference in collaboration with FMOH

Picture 9: SEUHP organized the first National Urban Health Conference in Ethiopia.

The first National Urban Health Conference (NUHC) was held from April 3-4, 2017 in Addis Ababa at the Hilton Hotel. It was organized under the theme of Ethiopia’s Urbanization and Its Implication on Health: Acting Now to Save the Future. The purpose of the conference was to share lessons and experiences between different scientific and experiential backgrounds in urban health and apply them to the current case of Ethiopia‘s growing cities. As a first conference on urban health in Ethiopia, the event is believed to serve as a foundation for current and future efforts in improving the lives of the country‘s urban population.

The objectives of the conference were to:

 Strengthen discussions regarding urban health problems in Ethiopia and outline benchmarks for - 59 -

future reference.  Review the implementation of the urban health extension program.  Assess the status of the urban primary health care reform model.  Discus on urban hygiene and sanitation practices and identify action points.  Advocate for healthy cities and towns  Identify action points to be implemented at different levels to improve urban health in the country More than 300 participants including mayors, policymakers, heads of Regional Health Bureaus, town health officials, service providers, donors and development partners, academics, agencies, private sector, civil society organizations, professional associations and others attended the two-day conference.

The conference was officially opened by H.E. Ato. Muktar Kedir, Policy, Planning and Evaluation Minister, Office of the Prime Minister; Good Governance, Justice, and Social Sector, Federal Democratic Republic of Ethiopia. High level officials Picture 10: Ato Muktar Kedir, Policy, Planning and Evaluation including Speaker of Addis Ababa City Minister, Office of the Prime Minister; Good Governance, Justice, Council, Chief of Health, Population, and Social Sector, Federal Democratic Republic of Ethiopia makes and Nutrition USAID, and the Chief the opening remark of the first national urban health conference. of Party of JSI/SEUHP gave keynote addresses on April 3, 2017 that was followed by exhibitions, presentations, plenary discussion among other activities. The conference was co-funded by FMOH and SEUHP.

The major outputs of the conference were:

 The conference ignited a discussion on urban health in Ethiopia and fostered an environment where connections and collaboration could begin.  Government officials, academics, professionals, industry leaders, and community members had the opportunity to continue their conversations surrounding urban health which will hopefully result in positive and targeted action.  Key WASH strategic documents were officially endorsed and made available for use.  Directions were provided on the urban health extension program and the urban primary health care model implementation.  Comments were obtained from key officials to improve hygiene and sanitation practices.  Conference organizers recorded thoughts, points, debates, and concepts discussed during plenary and concurrent sessions in a final document for distribution to policymakers and partners. The document is intended to streamline the efforts of multiple partners represented at the conference and offer actionable items and ideas to the governing bodies within urban

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health in Ethiopia‘s cities/towns.  Videography, photos, and publishable materials developed will be used for further JSI efforts in enhancing the current urban health program  The conference served as a forum to discuss the challenges towns and cities are facing in promoting urban health and to identify key next steps to address the challenges.  The conference was concluded by selecting the host city for next year. Harar was selected by majority vote to host the next National Urban Health Conference after bidding with other two nominees, Mekele and Wolayta Sodo towns.

NB: Further detail on the national urban health conference can be obtained from the conference proceedings.

Sub IR 3.2: Improve urban health data collection, analysis, and utilization

3.2.1 Support FMOH, RHBs, and C/THOs to strengthen the implementation of the data management system for the UHEP

As part of the health system strengthening support being provided to RHB and C/THOs, SEUHP is committed to the standardization and distribution of UHEP service data recording tools (SDRTs), including service data recording format, HTC register, report compilation format and referral slip. In FY17, SEUHP continued supporting the implementation of data management and use at C/THO level through regular SS and on-site coaching. SEUHP also reprinted and distributed a total of 1767 Service Data Recording Tools (SDRTs) and 1917 Referral Pads to all SEUHP-supported regions.

In FY17, UHE-ps and their supervisors received supportive supervision from regional SEUHP team on how to improve recording, reporting and documentation. Follow up was made to ensure the proper recording, reporting, and use of data for decision making at C/THO and program levels. Checking the availability and utilization of pregnant mother‘s registration, under-1 year old children registration, PLHIV registration and service recording tools were part of the overall support to UHE-ps. Supervisors and HCs are also supported to carry out LQAS to UHE-ps on monthly basis.

Besides, Addis Ababa SEUHP regional team undertook a wide range of activities to strengthen the data collection, analysis and use at UHE-ps, HC, and sub-city levels. The major activities include: training on daily activity recording and reporting for 27 UHE-ps and 3 supervisors, developing automated reporting tool, strengthening regular implementation LQAS, providing technical support during the routine SS and monthly supervisors meeting. Also, 63 UHE-ps and health workers from the two new SEUHP implementation towns from SNNPR (Boditti and Yigalem) received one day orientation on the SDR and reporting tools.

3.2.2 Develop electronic database to facilitate timely reporting of supportive supervision findings

SEUHP introduced an electronic database/mobile data system using Open Data Kit (ODK) to capture supportive supervision and DQA findings on regular basis and to get real-time information and feedback for decision making. The tool with its application was shared to Technical and M&E Advisors and was tested using personal android version smart phones while SEUHP was processing the procurement of android tablets dedicated for such activities.

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The monitoring evaluation and research (MER) team together with the technical team revised the paper- based supportive supervision tools and the electronic version was revised accordingly. Android tablets have been procured and distributed to every Cluster Coordinator and M&E Advisors. As of the first quarter of FY18, routine SS activities will entirely be based on the electronic app. The electronic system will serve as instant information so that the program can make real-time improvements and will facilitate timely decision making. The electronic data collection has multiple advantages over the paper- based data collection approach including timely submission of data, resource efficiency (time and avoiding data entry), data quality, etc. The use of e-data collection will continue being used in SEUHP‘s DAQ, study, and other activities.

Over the last two years, JSI/SEUHP had been using MySQL-based Database system that was developed by an external consultant to enter the routine data. Due to problems related to generating/computing quarterly reports which manifested in inflation or multiple counting of cases; incomplete categories on HTC related variables like the absence of lowest age groups (10-14 years); and lack of administrative privileges, SEUHP has had challenges fixing irregularities. SEUHP was also not getting timely corrective actions/services from the external consultant. The partnership with the external consultant was not going as expected and was cancelled. The central M&E unit decided to develop a new MS-Access based Database that has replaced the existing system. After putting a full back up of the data at regional and central office levels, the newly designed and developed database was put into effect in the second quarter of FY17. The new database is prepared internally by the data analyst at the central office. The database has been pilot tested and is currently fully operational in all SEUHP-supported regions. The new data base minimizes time to enter data and it is simpler to analyze and control data quality. In addition it has a dashboard to analyze core indicators information that will maximize data use for decision making at different levels.

3.2.3 Support implementation of urban community health information system (UCHIS) in SEUHP target cities/towns

The lack of a standardized national health information system to monitor the performance of health services delivered to the community by UHE-ps is hindering the efforts made in the UHEP. To fill this gap, the FMOH initiated the development of a standardized and harmonized system in line with the reformed health management information system (HMIS) indicators. The Urban Community Health Information System (UCHIS) is a tool designed to be used for data collection and documentation to meet the necessary information needs for providing family focused promotive, preventive, and environmental health services at the family level in urban communities.

Tool development and finalization: In FY17, following the decision made by the FMOH to introduce the paper-based CHIS while working on the electronic platform, SEUHP, as a member of the national TWG for Urban CHIS, worked actively with the FMOH and other partners to finalize the UCHIS guidelines, CHIS tools, and CHIS training manual (registers and individual health cards). The package is prepared in the form of a community folder that serves 5-12 families. eCHIS: So far, SEUHP has been providing technical support in the development of the electronic platform for eCHIS together with JSI/HMIS. In this reporting period, SEUHP participated in the eCHIS validation workshop held in Adama whereby the electronic platform was presented and feedback was provided by workshop participants.

Pilot-testing of the CHIS: SEUHP is currently supporting the pilot-testing of the paper-based CHIS through printing and distribution of tools and community folders and cascading of training to UHE-ps - 62 -

and their supervisors in SEUHP supported towns/cities. A TOT was organized by the FMOH with the financial and technical support of SEUHP. Participants in the TOT included SEUHP‘s M&E advisors, cluster coordinators of the selected towns, HMIS officers from the three regions, and participants including the UHE-ps supervisors. The training was cascaded for each of the selected kebeles in the respective regions and 122 participants attended the training (23 in SNNPR, 76 in Addis Ababa and 23 in Oromia). The piloting is taking place in seven kebeles/HCs in three regions: Addis Ababa (Entoto 02, Arada 03 & Kolfe Alem Bank HCs); Oromia: Bishoftu town (Kebele 01 and Kebele 02); and SNNPR: Hawassa town (Gebeya Dar and Leku Kebeles). The baseline data collection was accomplished between May and June 2017 in all the pilot sites. The CHIS materials (folders with the respective tools and user manuals) were printed and distributed to the sites. Baseline data have been collected in the three pilot towns which helped the categorization of households according to the standard in the revised UHEP implementation manual. The household profiles collected by using the CHIS tools were organized by community folders to facilitate the targeted service provision to households and their families. The pilot implementation has been going on since August 2017. Lessons learned starting from the TOT until the last day of the pilot testing period will be documented and shared with the FMOH and its implementing partners.

As part of the implementation process, a total of 65,961 UCHIS cards of 14 different kinds were distributed for 63 UHE-ps working in seven Kebeles in SNNPR, Oromia, and Addis Ababa. Additionally, open shelves, health education registers, UHE-ps field logbooks, referral registers, monthly tally sheets, quarterly and annual service delivery reports, and tracer drug availability tally sheets were distributed to pilot sites.

Table 8: UCHIS cards distributed by region, July-Sept, 2017

SNNPR Oromia Addis Regions (Hawassa (Bishoftu) Ababa Total ANC 565 649 1600 2814 PNC 565 649 1600 2814 FP 618 710 1751 3079 CH & Nutrition 242 279 687 1208 TB 727 836 2060 3623 HIV 2424 2786 6868 12078 Breast ca. 882 1014 2500 4396 Cervical ca. 882 1014 2500 4396 Prostate ca. 594 682 1682 2958 Asthma 1212 1393 3434 6039 Mental Health 1212 1393 3434 6039 Epilepsy 1212 1393 3434 6039 Cardio Vascular diseases 1212 1393 3434 6039 Diabetes Mellitus 1212 1393 3434 6039 Total 13,559 15,584 36,818 65,961

3.2.4 Work with Addis Ababa University School of Public Health and selected urban

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demographic health surveillance sites to generate evidence on urban health

Since FY15, SEUHP has been collaborating with AAU/SPH to generate evidence in the area of urban health issues for policy decision-making. In this reporting period, SEUHP collaborated with AAU/SPH on two key studies: 1) mapping the risk and vulnerability of urban residents to health and health-related factors; and 2) assessing the quality of the UHEP service delivery focusing on UHE-ps‘ adherence and competency in line with the revised UHEP IM. SEUHP partnered with researchers from AAU/SPH to conduct an appraisal assessment of the primary health care reform initiative. The assessment findings were presented at Ethiopian Public Health Association‘s annual conference in March 2017. SEUHP provided field-based support during the data collection through facilitation in consultation with the respective regional health bureaus and following up with data collectors. SEUHP also provided constructive feedback on the data entry template before data entry was started. Currently, the study team has submitted draft reports of the two studies. The final technical report and its dissemination are expected to be done in November 2017.

The Center for Urban Health Development (CUHD)/AAU organized two rounds of media forums on urban WASH to make urban health evidences into use through mobilization and engagement of media. An urban newsletter has been prepared to promote urban health. The participants were representatives from government and private FM radios, Newsletters, TV broadcasting centers and FMOH‘s communication department. The panelists/speakers were from Ministry of Health, Addis Ababa CA Water Sewerage Authority, Addis Ababa FMHACA, and Addis Ababa CA Solid Waste Management office. AAU/SPH had a booth corner at the Ethiopian Public Health Association (EPHA) Annual Conference held in Harar to advocate for the CUHD. At this conference, major findings of the PHCU reform appraisal were presented by one of the experts engaged in the appraisal. During the reporting period, AAU/SPH also developed a policy brief entitled ‗Social determinants of urban health in Ethiopian context‘. CUHD has also organized two rounds of Think Tank Group meetings. Meetings participants discussed: documentation of the PHCR; media advocacy; and the possibility of establishing urban Demographic Surveillance sites. The center also organized seminar for generic UHE-ps students at Minelik Health Science College to discuss on the experience of urban health extension program by FMOH; the role of CUHD_E for Urban Health Extension Professional's training by AAU/SPH; urban health program challenges and prospects by AAU/SPH; and impact of the UHEP in improving health outcomes of the community finding by the college.

Sub IR 3.3 Improve systems for commodity mobilization and distribution for key urban health intervention areas

3.3.1 Advocate for improved supply chain system for UHEP and address current supply needs of UHE-ps.

A series of discussions and advocacy meetings were held in RHBs, C/THOs, and HCs with other stakeholders on supply needs of the UHEP as indicated in the revised manual. As indicated in the manual, UHE-ps should be supplied with short acting contraceptives, HIV test kits, dipsticks for pregnancy testing, dipsticks for diabetes, RDT, iron capsules, paracetamol, anti-malaria drugs, and first aid kits. These meetings resulted in getting contraceptive supplies, condoms, and HIV test kits to UHE- ps in many towns in Amhara and Oromia regions. Greater effort is needed to make sure that other supplies will be availed to the UHE-ps. In Jimma town, it was agreed to refill supplies and related

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material for urban health program using the existing Integrated Pharmaceutical & Logistic System (IPLS).

Sub IR 3.4: Strengthen organizational capacity of partners to perform core functions of UHEP

In contribution to the PEPFAR country ownership strategy implementation, SEUHP works with Emanuel Development Association (EDA) to build on existing infrastructure and improve the ability to mobilize, design, implement, and monitor the UHEP. In FY16, SEUHP supported the organizational capacity assessment (OCA) of EDA and many major gaps were identified. Based on the findings, priority was given to the human resource and M&E gaps. In the first quarter of FY17 SEUHP supported revision of EDA‘s human resource management and is reviewing the draft version. M&E training was also provided to staff members of EDA in Amhara and Afar regions at Debre Birhan town for 23 participants including program and M&E personnel and the area manager. The training covered basics of M&E; M&E frameworks (conceptual, logical, and results); indicators; data collection, summarization, and presentation; data quality assessment; success stories; and best practices. M&E advisors from Addis Ababa and Amhara SEUHP offices facilitated. For further capacity development, SEUHP linked EDA with Kaizen, a USAID-funded project. The OCA report was communicated to Kaizen for future action. SEUHP efforts will not be duplicated, however, because Kaizen is involved in capacity building for local development organizations. There have been a number of coaching visits, meetings, and discussions with EDA on the project implementation standards and achievements. SEUHP‘s Addis Ababa, Amhara, and central office staff members supported the development of EDA‘s annual plan by incorporating lessons from previous implementation experiences.

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PART 1.4: IMPROVE SECTORAL CONVERGENCE FOR URBAN SANITATION AND WASTE MANAGEMENT (IR 4)

Ethiopia‘s "One WASH" national program aims to improve the health and well-being of communities in rural and urban areas in an equitable and sustainable manner by increasing access to improved water supply, sanitation, and hygiene facilities and services, and promoting good hygienic practices. Improving the quality of existing latrines is one of FMOH‘s priority activities in its health sector transformation plan (HSTP). In FY17, SEUHP conducted several multifaceted activities to contribute to the achievement of these national goals.

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Sub IR 4.1: Increase WASH governance and management capacity at all levels

4.1.1 Support the implementation of integrated urban sanitation and hygiene strategy (IUSHS)

In FY17 SEUHP in collaboration with FMOH organized the first national urban health conference. One of the key achievements of the national urban health conference was the endorsement/inauguration of the Integrated Urban Sanitation and Hygiene Strategy (IUSHS). As indicated in the below figure (figure 1), seven key Ministries of the government of Ethiopia; the Federal Ministry of Health (FMOH); Ministry of Water, Irrigation and Electricity (MoWIE); Ministry of Urban Development and Housing (MoUDH); Ministry of Finance and Economic Cooperation (MoFEC); Ministry of Education (MoE); Ministry of Forest, Environment and climate Change (MoFECC); and Ministry of Culture and Tourism (MoCT) signed MoU in April 2017. SEUHP also gave technical support to FMOH to in formatting the IUSHS, the Strategic Action Plan (SAP), Implementation Guideline (IG), and Memorandum of Understanding (MoU). The MoH printed these documents and planned to be distributed in FY18.

Picture 11: Signing of the Memorandum of Understanding of the Integrated Urban Sanitation and Hygiene Strategy (IUSHS) by the seven ministries of Ethiopia.

Following the national level endorsement of the strategy, SEUHP provided technical and resource support to regional health bureaus of SNNPR, Amhara, Oromia, and Tigray regions with the aim of contextualizing the IUSHS including its Strategic Action Plan (SAP), Implementation Guideline (IG), and Memorandum of Understanding (MoU) into the regional contexts through the participation of various Regional WASH actors. A total of 45 experts from different relevant sectors attended the contextualization workshop and translated the MoU into Afan Oromo language. Similarly, town level orientations were done in Gonder, Deber Markos, Dessie, Debere Birhan, Maychew and Aksum towns. The participants at each level provided important feedbacks that were useful to enrich the draft document.

4.1.2 Previously established WASH platforms supported and new platforms established - 67 -

4.1.2.1 Strengthening/revitalizing existing WASH platforms

In this reporting period, SEUHP continued to collaborate with different public sectors actors to build a strong working relationship and obtain commitment from local government agencies, ensure increased institutional collaboration among the sectors, minimize duplication of efforts, and maximize use of resources.

Accordingly, different activities were performed in SEUHP supported regions:

SNNPR: Based on the gaps identified, a three-day capacity building training was organized on different WASH issues for 15 WASH Technical Working Groups of Soddo and Arbaminch towns. A total of 9 individuals (1 female) from Soddo and 6 persons (1 female) from Arbaminch towns attend the training. The training was facilitated by professionals from RHB and JSI/SEUHP. Liquid and solid waste management, personal hygiene, household water treatment and storage, community engagement approaches and planning tools for the urban context and coordination mechanisms for WASH sector actors were some of the topics addressed during the training. The performance of the 2009 EFY were discussed by participants and the integrated WASH plan as revised for the 2010 EFY. Finally, an action plan was prepared by the participants to improve the performance of their activities.

Addis Ababa: City level WASH TWG of the platform discussed and agreed to collect baseline data on the current WASH situation at health facilities. In this reporting period the city WASH TWG in collaboration with SEUHP conducted an inventory of WASH facilities in all public health centers of the City Administration. SEUHP provided technical support during the development of protocols and data collection tools. SEUHP also organized training for data collectors for the baseline assessment and was actively involved throughout the assessment process. Findings of the assessment will be used to inform the planning process at different level and design appropriate WASH interventions in FY18. SEUHP has also given technical and resources support to conduct sub-city level WASH steering committee meetings to strengthen inter-sectoral collaboration among WASH sector actors.

Amhara: SEUHP in collaboration with the Regional Health Bureau (RHB) organized a three-day capacity building training on different WASH topics identified as gaps. A total of 66 WASH TWG members (16 female) from Gondar, Debre Markos, Deberetabor, Wolidya, and Debere Birhan towns attend the training. Topics of the training included: public health importance of urban sanitation and waste management, proper solid and liquid waste management approaches in urban context, personal hygiene, household water management and safety, communality engagement approaches, and tools. At the end of the training, the WASH technical working groups of each town prepared a six-month action plan and submitted it to the RHB for follow up. After the training, he Debre Tabor TWG conducted monthly meetings, developed proposals for 4 public and 4 communal latrine constructions and the plan was submitted and approved by the Town Administration. Similarly, the Woldia WASH TWG meetings held meetings twice, provided technical support to solid waste collection associations, kebele administrations about waste management, and discussed with Hotel owners regarding the need for regular medical checkups for food handlers. A hygiene and sanitation capacity building training was organized in Dessie town in collaboration with the Beautification office for health professionals, other WASH sector professionals, unit leaders, media professionals (FBC, FM and Radio) among others. SEUHP also provided technical and resources support to Kemissie town administration to facilitate second level higher officials meeting. A total of 30 (5 female) WASH steering committee and technical working group members attended the meeting. The participants discussed on the action plan

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developed by technical working group (TWG) and commented to consider the community mobilization and the involvement of private sectors to be included in the work plan.

In this reporting period, SEUHP supported an experience sharing visit focusing on WASH conducted by Debere Tabor, Debre Markos, Debre Birhan, and Dessie TWGs members on different issues. Dessie WASH TWG members traveled to Shewa Robit to take experience from EDA on briquette and biogas production. Debre Birhan WASH TWG travelled to Hawassa to learn about hygiene and sanitation management of the city. Debere Tabor and Debere Markos towns used the experience from Bahir Dar to link the solid waste collection service fee collection system with the water bill. This helped to establish sustainable waste collection system and enhance working relationships between community, government and private solid waste collection associations.

Tigray: In this reporting period, a rapid functionality assessment of the established WASH platforms was conducted at Aksum, Shire, and Maychew towns using a checklist. SEUHP in collaboration with the TWG members of each town shared the assessment findings to the TWG and steering committee members. A total of 39 participants (16 from Aksum, 12 from Shire, and 11 from Maychew) attended the meetings. SEUHP in collaboration with the respective town health offices organized a three-day capacity building training for urban WASH technical working members of 50 participants (23 female) of Alamata and Aksum towns. With the technical and logistical support from SEUHP, Shire town TWG organized review meeting facilitated by the Mayor, for 48 participants (17 female) from WASH sector offices, university, private organizations, religious leaders, and community representatives. Based on identified gaps, a three-day capacity building training was organized on WASH for 49 (5 female) TWG members of Aksum and Adigrat towns.

Dire Dewa: The WASH TWG organized a three-day workshop and developed a MoU for the WASH sectors and integrated work plan as per the guidance from WASH steering committee. SEUHP facilitated the meeting.

Oromia: During the reporting period, WASH capacity building training was provided for 22 (five female) WASH technical working group members from Jimma and Bishoftu for four days each. The main objective of the training was to build the capacity of the WASH technical working group and develop a 2010 EFY WASH activity plan. After the capacity building training, 300 roadside dust bins (figure 3) were installed on main roads. The team also facilitated recruitment and deployment of 80 street cleaners, identified open solid waste disposal sites in the town, and did gardening of two road side greenery sites.

Additionally, a town level experience sharing visit was organized in Jimma town with THO and other stakeholders. SEUHP supported participated in the selection of a well performing kebele in the area of WASH. During the experience sharing visit, different government sectors including Jimma town health office staff, representatives from women and children affairs office, Jimma town WASH technical working group, UHE-ps, supervisors, Jimma town Environmental protection agency, Jimma FM 98.1, and Governmental communication office participated in the visit. The visit mainly focused on model families that implement urban WASH activities using 1-5 networks. The Jimma town health office advised replicating lessons from the visited kebele to other areas.

4.1.2.2 New urban WASH platforms established in 20 towns

In this reporting period, SEUHP supported the establishment of WASH platform in 18 towns i.e., (7 in Amhara, 2 in Oromia, 4 in SNNPR, and 3 in Tigray regional states). In each of the towns, 2-3 days - 69 -

workshops were organized and a total of 182 participants (41 females) attended the workshops. Workshop participants discussed the challenges of urban sanitation and waste management, and the importance of establishing WASH steering committee and technical working group. Some of the major achievements of the newly established and revitalized WASH platforms included the following:

Oromia: In Adama town the platforms maintained hand washing facilities near toilets; identified solid waste disposal sites; and sacks were prepared for temporary collection and linked to Micro and Small Enterprises. Forty-seven sector staff participated in a sanitation program carried out in their Kebeles. Through efforts of the WASH technical team, comprised from different sectors, about 306 meter cubed of solid waste and more than 10,000 liters of liquid waste were collected from hidden pocket areas by a Municipality truck from Adama kebele 08 and 09. Food and drinking establishments were inspected and some of them were penalized for not properly disposing of solid wastes generated and observed within 50 meters radius from the establishments. Jimma town WASH platform assigned Jimma Aba Buna football club as the town Sanitation Ambassador and conducted sanitation campaigns twice a month in collaboration with the THO and Town Greenery and Beautification Department. The idea of having a sanitation ambassador was initiated by SEUHP but the selection was done by the platform.

Tigray: The Maychew town municipality recruited and deployed new street/road cleaners and the number of cleaners increased from 12 to 40 people. The town council declared monthly town level sanitation campaigns on the 23rd of every month. The town administration allocated budgets to construct slaughter houses and public latrines. Aksum town has rehabilitated slaughter houses. Mekelle city administration recruited 5,000 people and deployed them to work on environmental sanitation and solid waste collection and management services with the support of a safety net program and food for work. Following the National Urban Health Conference, the city administration is doing major restructuring to strengthen the sanitation and beautification department.

Amhara: The TWG of Debere Markos and Gonder towns organized a sanitation campaign led by Mayors of each town. The TWG of Debere Markos town conducted water quality tests, the inspection of food and drinking establishments and reviewed their performance and revised the joint WASH action plan of the town.

4.1.3 Support national, regional, and city/town level WASH movements

In FY17, SEUHP provided support to MOH, RHB and city/town health offices in organizing national, regional and city/town level WASH movements to advocate for improved urban sanitation and waste management practices. Following the national urban health conference, Debre Markos town administration organized a three-day campaign led by the Mayor. Harar town organized an advocacy workshop for improving sanitation, hygiene, nutrition and other health related practices. About 120 participants from the six Woredas including administrators, health coordinators, Kebele leaders, religious leaders, community representatives, UHE-ps, UHE-ps supervisors, RHB experts and City municipality participated in the workshop. The workshop was facilitated by higher officials of Harari regional health bureau and Harar city municipality manger.

With technical and logistical support from SEUHP regional office, Mekele city health office and the regional health bureau organized WASH campaign in collaboration with Tigray Artists Association, city administration and TRHB. More than 200 members of Tigray Artists Association and thousands of community members participated during the campaign.

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Sub IR 4.2: Increase supply of low-cost sanitation and hhygiene pproducts, ffacilities, and sservices

Increasing the supply of low-cost WASH products/facilities and services is key to increasing WASH- related health benefits. In this regard, SEUHP‘s support focuses on the promotion of household and community-level sanitation and hygiene facilities and proper utilization of those facilities and services. In this reporting period, the following key activities were accomplished under this sub IR.

4.2.1 Organize sstructured international learning trip on WASH

Ethiopia has made impressive progress over the past 10 years in reducing poverty and ensuring urban development by upgrading slum areas, constructing condominium houses with WASH packages, involving micro and small enterprises in waste management, and increasing access to WASH services. To build on these initiatives and development activities, in FY17, SEUHP planned a structured learning visit to other countries. However, following the discussion held with FMOH, it was learned that Ministry of Urban Development and Housing organized similar visit in Rwanda, Kigali in March 2017. Due to this the proposed learning trip is canceled.

4.2.2 Create model WASH demonstration sites in selected cities/towns

The promotion of improved sanitation and hygiene facilities and services is integral to sustainable WASH programs. UHE-ps and HDA members are key promoters of improved sanitation and hygiene facilities and services at the household, school, youth center, and community levels. Model WASH demonstration sites help to build the technical capacity of UHE-ps and HDA members to promote standard and high-quality services, products, and facilities in their respective work areas. In FY17, JSI/SEUHP planned to expand the model WASH demonstration site from Nigus Teklehaymanot primary school in Debre Markos town to other towns/cities to make WASH education more practical and easier to understand. The Model demonstration site comprises of shower/bathroom, improved latrine, hand washing facility, household water management, on-site solid waste handling, grey water soak away pit, menstrual hygiene management (in school), impregnated mosquito net, and household level solid waste composting.

The Amhara SEUHP team identified three schools in Debre Markos, Bahir Dar, and Gondar towns to create model WASH demonstration sites. So far, WASH facility rapid assessments have been conducted in Gondar and Debre Markos towns. Based on the findings, SEUHP supported the maintenance of model latrine, water pipe extension, linking hand washing facility to latrines, and installing a water tanker in Nigus Teklehaymanot primary school. As part of this effort, in the first quarter of FY17 SEUHP in collaboration with Red Cross Society, trained 31 people (eight men; 23 female; of whom 25 were students, five teachers, and one UHE-p) including members of school health clubs, HIV clubs, and Red Cross clubs for three days on school sanitation and hygiene practices. In Dessie town water pipe line extension, installation of hand washing facility near the latrine and maintain of the latrine facilities are implemented to demonstrate WASH models.

With the objective of sharing lessons from school based intervention of UHEP and on how UHEP packages are implemented in schools, a national level experience sharing visit was hosted by Debre Markos town from February 20-21, 2017. Twenty-five technical people (four female) from Oromia, Amhara, SNNPR, Harari, Dire Dawa, and Addis Ababa participated in the experience sharing visit.

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After an official welcome by Deputy Mayor of Deber Markos town, the town health office head, town education office, school director, and health center head gave brief presentation on their achievement, challenges and solutions made to address those challenges. A site visit was then conducted at the model school, Wuseta HC, UHE-ps‘ office, and at HH levels.

The following were the key lessons from the learning trip:

At the health center level, quality and standard services are being provided by UHE-ps using the health extension package models (latrine, hand washing facility, liquid waste seepage pit, smokeless stove, etc) at the health center, schools, and Kebele sites. UHE-ps are supporting the better implementation of UHEP package at different levels through: preparing lesson plan for health education being conducted at health center; using model demonstration facilities during health education. The collaboration between the HC and other sectors such as the university, the Police College and HC staff support to UHE-ps are key lessons witnessed by the visiting team. However, there remains a need for: maintenance of demonstration facilities and increasing community referral linkage were recommended by the visiting team.

At the kebele level, health extension package models were present where UHE-ps are located and UHE-ps are educating HDAs using the model demonstration facilities, well organized documentation system, integration with other stakeholders – including school directors and presence of daily activity direction are the major lessons.

Picture 11: Health club members – those students who had a vision to be health professional explaning critacl times for handwashing using models developed by the students At the HH level, it was learned that model demonstration sites are implemented at household levels.

HDAs are categorized as A, B or C based on their performance and plan of action, documentation status of HDAs meeting minutes, good level of awareness on health extension package. Households are also implementing resource oriented waste (solid and liquid) management by linking with urban agriculture activities. The visiting team recommended the scale up of the HHs‘ performance and to sustain its implementation.

At the school level: Some of the positive things observed at school level include the fruitful collaboration between Negus Teklehaimanot primary school and UHE-p; the presence of health extension package models (WASH facilities and other health facilities) at school; and availability of - 72 -

space for menstrual hygiene. Besides, enhanced role of min-media to teach students; and the commitment of school director, teachers, and other school administration staffs together with the commitment of UHE-ps in implementing the health extension package at schools was noticeable.

Following the experience sharing visit conducted at Debre Markos town, seven towns; Amhara (two towns), Oromia (one town), SNNPR (one town), Addis Ababa, Dire Dawa, and Harar were committed for the implementation of model WASH facilities demonstration sites. The demonstration site comprises of shower/bathroom, improved latrine, hand washing facility, household water management, on-site solid waste handling, grey water soak away pit, menstrual hygiene management (in school), impregnated mosquito net, and household level solid waste composting.

The following section describes progress made after the learning trip:

Harar: Following the experience sharing visit to Debre Markos, SEUHP in collaboration with experts from the RHB selected one school and a HC as model demonstration sites in Harar. Currently the school and HC staff members have started implementing WASH related activities. The kebele in which the HC and school are located is selected to implement model WASH interventions that can be replicated into other kebeles of Harar town.

Amhara: Based on the lesson learned from Nigus Teklehaymanote primary school and Wuseta Health center at Debre Markos town, model demonstrations are being implemented in five schools and in all health centers available in Debre Markos Town. The participants of the visit from Gondar and Bahir Dar also started to implement model demonstration site in schools and health centers.

EDA with the support of SEUHP provided technical and resources support for Debre Birhan town health office in the process of creating model village specifically on hygiene and environmental health component of UHEP. As part of the process in the creation of a model village, Kebele leaders mobilized the community cleaned an area that used to be a solid waste disposal site About 150 people participated on the sanitation campaign to clean the waste from the village. Now the village and waste site in the village is cleaned, fenced, and seedlings planted. The kebele administration has planned to handover the site for youth to be used as in income generation site. Similar preparations such as selection of a model village, baseline data collection, and training of HDAs on UHEP packages were conducted in Dessie.

Oromia

Dire Dawa: Three experts visited the model School WASH demonstration practice at Debre Markos town. Currently, the regional health bureau, health center, and the school are preparing integrated plan to create demonstration sites at Kebele level.

Addis Ababa: A school and a health center were selected from Akaki Kality sub city to implement the pilot WASH facilities demonstration activities. The team who participated during the experience sharing visit developed an action plan and organized a one day consultative meeting to share what the team learned from the visit. Following the consultative meeting and the approval from higher officials, the team in collaboration with SEUHP and EDA renovated WASH facilities in the selected school, organized a half day discussion with UHE-ps working in selected health center and school, and developed detail design and technology options to be implemented in the selected health center. The health center is undertaking the construction of the demonstration site.

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Besides, SEUHP /EDA in collaboration with Yeka sub city health office selected Woreda 12 in Yeka sub-city as model village for the implementation of hygiene and environmental health package by engaging the community of the selected kebele. Baseline data was collected and discussions held with stakeholders, HDA members, community and civic society representatives.

SNNPR: The lessons learned during this experience sharing visit were shared with 36 participants (F=15) through a one day sensitization workshop for teachers of three schools, staff of three health centers and UHE-ps. The workshop was organized by Sodo THO using its own resource. At the end of the meeting, the participants prepared an action plan for developing demonstration site with the required sanitation and hygiene facilities in their respective school and health center. As a result model demonstration rooms for WASH activities are established in Wolaita Soddo town in Soddo Health Center, Ligaba primary school, and Damota Kebele. The sanitation technology options for those demonstration rooms will be equipped in the coming quarters of FY18.

In addition to this, SEUHP provided technical and logistical support to town health offices for the implementation of key sanitation, hygiene and greening activities in the selected model Kebele (Fana Kebele, ―Ersha sebel Mender‖) with high sanitation waste management problem through community participation in Wolaita Soddo town. The baseline data was collected by UHE-ps and SEUHP did the analysis.

Picture: 12 Partial view of the site before and intervention

Following the baseline assessment, Wolayta Sodo town health office in collaboration with SEUHP regional team facilitated one day HDA orientation session to enhance the involvement of community in addressing urban sanitation and waste management problems. A total of 134 HDAs attended the orientation. Action plan was prepared by the participants. Awareness creation through HDAs and urban health professionals and protection of major waste lands that the community is using to dispose solid waste were identified as priority activities. Protection of the site from illegal damping of solid wastes and entrance of animals using wire fence and the planting of variety of

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4.2.3 Develop and distribute sanitation and hygiene ladder IEC/BCC materials

In FY16, SEUHP developed and distributed WASH job aids to facilitate standardized promotion of improved sanitation and hygiene facilities and services through UHE-ps and HDA leaders. The sanitation and hygiene ladder, which includes the latrine ladder, hand washing practice ladder, and household water management ladder, are included in the job aid. In most of the regions, UHE-ps were not using them as expected mainly because of lack of proper orientation on utilization of the materials. In this reporting period, orientation was given to UHE-ps by integrating with the regular supportive supervision visits and during monthly meetings. In addition, FMoH in collaboration with JHU, SEUHP and other partners organized new initiative to standardize the messages for IEC/BCC materials including the family health card, and to harmonize WASH and NTD messages. SEUHP gave technical support in customizing the family health card, and harmonization of neglected tropical diseases and WASH messages.

4.2.4 Test Public-Private Partnership (PPP) model on uurban ssanitation and waste management

The findings of SEUHP‘s urban sanitation and waste management situational assessment that were conducted in 2014 indicated that the current public-private partnerships in Ethiopia are not uniform throughout cities/towns in the country. Additionally, there is no clear responsible government institution with policies and guidelines to promote engagement of the private sector on urban sanitation and waste management service delivery. This is mainly due to the lack of financially viable business models to attract the involvement of the private sector in sanitation and waste management service delivery. In FY17 SEUHP implemented the following key activities;

4.2.4.1 Implement financially viable business model for public latrine management

A standard model engineering design, a Bill of Quantity, and an Environmental Impact Assessment for newly designed public latrines was developed. SEUHP engaged a consultant to study the private sector involvement in urban sanitation and waste management service delivery as well as the existing PPP practices in solid waste management, pit emptying service (liquid waste management), public toilet management, and waste recycling services.

In this reporting period, SEUHP accomplished the following key activities by engaging the consultant:

 A public toilet management model has been developed after reviewing the draft business model created by SEUHP which will be tested in FY18; findings of the existing public toilet management assessment in Ethiopia; and literature from national and international experiences on public toilet management.  In line with the developed public toilet management model; o Training materials on entrepreneurship and business skills have been prepared. o MoU that will be signed by different stakeholders for the proper implementation of the model has been developed. o Alternative sources of financing for public toilet operators for integrating different income generating activities have been identified/explored. o Discussions were held with EDA and key stakeholders in Adama city to advocate the developed public toilet management model for testing in the existing public toilets.

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o Existing public toilets operated by Micro and Small Enterprises (MSEs) in Addis Ababa (supported by EDA) and Adama were visited by SEUHP team and public latrines identified to test the public latrine business model. o Assessment of private sectors involvement in urban sanitation and waste management service delivery is conducted in Addis Ababa, Dire Dewa, Mekele, Bahir Dar, Adama, Hawassa, and Harar.

4.2.4.2 Implement model technology options for urban sanitation and waste management services

The urban sanitation and waste management situational assessment finding indicated that though 91 percent of urban residents had access to latrines, they are predominantly traditional pit latrines (71 percent), which may not sustain utilization because of bad smell and does not break disease transmission routes. Additionally, a majority of the households (88 percent) use sacks to store garbage at the source until it is collected. The same study also indicated that about half of the households handle grey water (household liquid waste) by openly discharging into any accessible public properties, such as streets and nearby open spaces. Even the existing facilities in some households (soak-away pits) could not accommodate the handling of daily generated liquid waste. These all require improved design and alternative technology options. To address the challenge SEUHP conducted capacity building trainings to UHE-ps, supervisors, and C/THO staff in FY16.

In line with this, in FY17, the following key activities were accomplished;

 As per the request from Debere Birhan town administration, SEUHP in collaboration with EDA provided 30 road side dustbins. The town administration wants to use these dustbins as a model and mobilize the private sectors to provide the dustbins. Awareness creation about proper solid waste management approaches is also presented to the community using the dustbins in collaboration with Debre Birhan University undergraduate nursing students.

 SEUHP in collaboration with RHB and Harar municipality facilitated the orientation of UHE-ps and kebele leaders on the management of waste and how to keep hygiene and sanitation practices. SEUHP also provided 80 roadside dustbins to Harar town administration. In recognition of SEUHP‘s valuable support Harari regional state president‘s office awarded a certificate of recognition to SEUHP.

 Similarly, SEUHP provided 80 road side dust bins for Adama town that will be used to mobilize the private sector

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Picture 13: Road side dustbins provided to Harari region by JSI/SEUHP, December, 2016, Harar

4.2.4.3 Build the management and technical capacity of private sanitation and waste management services providers

SEUHP‘s urban sanitation and waste management situation assessment findings indicated that although the primary solid waste collection services are outsourced to private microenterprises, the current cost recovery is very low and cannot recover the cost invested for staff salary, transport, maintenance, and other operational expenses. SEUHP organized experience sharing visits, advocacy workshops, and capacity building trainings for SMEs (private organizations) involved in urban sanitation, aiming to establish sustainable financial and service delivery systems.

In this reporting period, Amhara regional SEUHP team, in collaboration with the RHB, C/THO and Town Beautification Offices, organized a two-day training on occupational health and safety for private solid waste collection service provider association members in Bahir Dar, Gondar, and Debre Markos towns. A total of 94 (28 Bahir Dar, 36 Gondar and 30 Debre Markos) trainees were selected from 21 SMEs (6 in Bahir Dar, 12 in Gondar and 3 in Debre Markos) who are providing solid waste collection service in their respective towns to attain the training. At the end of the training, the trainees developed an action plan, and the town sanitation and beautification offices took on the assignment of leading the implementation of the planned activities. As per the commitment, Gondar town administration with special approval from the Mayor‘s Office allocated one million birr for all associations to help them fulfill personal protection equipment (PPE) and other working materials.

Similarly, training was provided for 29 HDAs for two days on liquid and solid waste management in Debre Birhan and Dessie towns. A one day WASH advocacy workshop was also organized for 69 (27 females) higher officials and members of private service providers in Bahir Dar and Debre Birhan towns.

SNNPR: SEUHP organized a one day capacity building training in collaboration with RHB, THOs and Town Administration Greening and beautification units for private sanitation and solid waste service providers (Small Scale Micro Enterprises) on occupational health and safety. A total of 119 participants (F=51); 31 in Hawassa (F=3), 41 in Wolaita Soddo (F=18) and 47 in Arbaminech (F= 30) towns attended the training. The participants were from six solid waste management service provider - 77 -

associations (SMEs). At the end, action plan was prepared by participants to implement safety measures and prevent health risks related to waste management.

Sub IR 4.3 Increased demand for high-quality sanitation and hygiene products, facilities and services

4.3.1 Build technical competency of UHE-ps through the WASH IRT

As part of its objective of enhanced technical excellence in service provision by improving the knowledge, skills, and attitude of UHE-ps in previous years, SEUHP supported the training of UHE-ps using the WASH IRT modules as presented under the IR1 section of this report.

Post training follow up was started in all the regions where SEUHP is working. The follow up was done by teams from respective THO trainers and SEUHP cluster coordinators using structured checklist. During follow up visit, most of the UHE-ps confirmed that the courses are very helpful to them in improving their knowledge, skills and attitude. Following the IRT, UHE-ps have been undertaking several activities which in many cases are attributed to the contribution of the knowledge and skills obtained from the training. For instance; UHE-ps at Shashemene town started planning for open defection free Ketenas, and UHE-ps at Bishoftu mobilized communities at two sites and helped them construct liquid waste drainage at sites which used to be known as unmanaged garbage site.

4.3.2 Conduct mass awareness creation using local mass-media

In Ethiopia, there are many FM radio stations and regional TV programs that can reach urban residences and play an important role in promotion and awareness creation on proper urban sanitation and waste management practices. In this reporting period, a radio magazine program with a focus on WASH was prepared in Amharic and Oromiffa and aired using the local media. The detail report is included under IR2.

4.3.3 Advocacy on sanitation and waste management through mass-media

In these reporting periods both central and regional offices organized different workshops or engaged mass media professions with regular activities. Urban sanitation and waste management services delivery are the major topics that print and audio visual media covered for mass awareness creation works as presented under the IR2 section of this report.

4.3.4 Strengthen hygiene and sanitation education by UHE-ps and HDAs through home visit and outreach

Urban sanitation and hygiene is an area that UHE-ps address daily and that takes much of their time. SEUHP has been providing technical and material support to UHE-ps through capacity building training, developing and distributing as well as giving orientation on printed educational materials including WASH job aids on proper latrine utilization, food safety and hygiene, household water treatment and safe storage, and hand washing. Additionally, family health cards were distributed to UHE-ps and HDA leaders. These job aids and IEC/BCC materials helped UHE-ps and HDAs conduct effective counseling sessions on key sanitation and hygiene behaviors.

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In addition to this, SEUHP team provided regular technical support for UHE-ps and their supervisors regarding hygiene, environmental health related disease/outbreak risky area identification; and prevention and promotion activities. SEUHP also gave technical and training material support to town health offices in Wolayita Sodo and Arbaminch towns to organize a capacity building training for Health Development Armies (HDAs) on WASH. The kebeles were selected by the THOs as model kebeles. This training aims at enhancing the involvement of HDAs in the process of creating model kebeles on WASH and other health activities. The training was mainly facilitated by UHE-ps. A total of 184 HDAs in 6 kebeles attended the one day training.

4.3.5 Celebrate Global Hand Washing Day

WASH related campaigns are great opportunities to mobilize communities, especially school children, to discourage harmful practices like open defecation and inappropriate solid and liquid waste management, and to promote positive health behaviors like proper hand and face washing. In the previous FYs, SEUHP has been supporting (technically and financially) regional health bureaus and C/THOs to celebrate the Global Hand Washing Day. Similarly, in this implementation period, SEUHP regional team in Addis Ababa organized celebration of the Global Hand Washing Day. It was held in Nifas Silk Lafto (NSL) and Yeka sub-cities. These events were conducted in Addis Amba primary school of Nefasilk Lafto sub-city on February 10, 2017; and Tesfa Berhan primary school in Yeka sub-city. More than 450 individuals, who represented teachers, students, WASH technical working group members, Woreda and sub-city health and education sectors, were involved in the hand washing ceremonies.

These events aimed to promote proper hand washing practice during critical times. The ceremony was participatory and featured question and answer competition between students, and hand washing practice games. The organizing committee also provided hand washing equipment (Jerry can with tap) and soap for the school. SEUHP team played a key role in organizing the events including printing of three banners and advocated for the importance of hand washing and toilet construction.

4.3.6 Strengthening school WASH activities in urban settings

As indicated in the revised version of UHEP implementation manual, schools are among the key areas targeted for the implementation of UHEP packages. However, UHE-ps have limited experience in involving in schools; in this reporting period, SEUHP regional teams supported the following activities:

Addis Ababa: The regional SEUHP team, in collaboration with sub-city health and education offices conducted school WASH assessment in selected public primary schools of Yeka (three schools) and Akaki Kality (six schools) sub-cities. Most of the school WASH facilities were found in poor hygienic condition and some were not functional. The major factors, which resulted in poor conditions of the WASH facilities in schools include: absence of functional hand washing facilities near to toilet; shortage of water due to interruption and insufficient tanker size that doesn‘t meet demand of the school; inadequate WASH facilities for the school community; old WASH facilities and absence of timely maintenance.

To improve the situation, two Woredas from Akaki and Yeka sub-cities were selected by EDA and SEUHP for WASH model sites. In these Woredas, two schools were selected as demonstration sites. SEUHP provided technical and material support to implement the WASH interventions at these schools. The major contributions include: sanitation campaigns conducted in Berhane Hiwot primary - 79 -

school (Yeka SC), Selam Fire and Fitawrari primary schools (Akaki SC): more than 3000 students and 40 teachers were mobilized for the sanitation campaign, brochures and posters were distributed, and proper hand washing practice was demonstrated for students.

SNNPR: Three days training was organized for 129 school administrators and club members in four towns (Dilla, Hawassa, Wolaita Sodo and Wolkite) and at eight schools (two schools from each town). School directors, teachers, Parent-Teacher-Student Association members, UHE-ps and their supervisors including health club members from students were among the training attendees. The training aimed at strengthening WASH activities at schools, increase the knowledge of school administration/teachers and club members, increase involvement of students in improving hygiene and sanitation in their communities, and strengthen the link between UHE-ps and schools. At the end of the training, each school prepared an action plan that can be implemented after the training.

After the training, technical support was provided to UHE-ps and school directors to implement school WASH activities in Nigist Fura primary school (Hawassa) and Ligaba primary school (Wolaita Sodo). Based on the technical support provided to them, Ligaba primary school in Wolaita Sodo did some encouraging activities using its own resource including: 16 new doors were fixed for male and female latrines to replace the existing old and non-functional ones; 10,000 liter water tanker was installed to minimize the problem of inconsistent water supply to the school; and constructed water pipe extensions for hand washing near female latrines; installed urinals for male students attached to male latrines; begun conducting regular sanitation campaigns; and has prepared a site for model household demonstration and visionary center.

Amhara: Similar to other regions, training was organized on school WASH for 57 participants (33 females) selected from club leaders, teachers, and parent teacher association members from two model schools in Gonder and Bahir Dar. Moreover, WASH facilities were renovated and First Aid kits provided to these model schools at Bahir Dar and Gonder. SEUHP also supported Nigus Teklehaimanot primary school. The school is practicing urban agriculture linking with grey water from water taps. They also convert organic wastes into compost to be used for vegetable production in the compound. Other schools in the town have started to implement the model demonstration facilities as per the experiences acquired from this school. As SEUHP has supported mini-media materials to the school, school clubs are conducting mass awareness creation using mini-media. Additionally, TWG members at Sekota conducted training on school WASH program to teachers who are leading the WASH clubs.

th EDA selected Atsie Zere-yakob primary Picture 13: SEUHP’s poster presetation during the 14 International school in Debre Birhan and Kara-gutu in Urban Health Conference, Coimbra, Portugal Dessie for low-cost Sanitation and Hygiene model demonstration site in collaboration with THO and educational office during the fourth quarter.

Sub-IR 4.4: Increase knowledge base to bring WASH innovations to scale

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4.4.1 Document and share best practices and lessons

In this reporting period, using the first national conference on urban health as opportunity documentations were prepared on; 1) mapping of public WASH facilities and 2) lesson from urban job creation and safety net program and its contribution for urban cleaning and beautification. Different private, governmental and nongovernmental organizations shared their experiences and innovative activities or best practices on urban sanitation and waste management products, waste recycling, and service provision through exhibition during the conference.

In FY17, SEUHP gave support to Ethiopian Environmental health professionals association to conduct its 2nd scientific conference with a theme ‗‘Towards a Healthy and Resilience Environment for Sustainable Development‘‘ focusing on Urban Sanitation. The conference was conducted in Jimma University for two days (24 -25 July 2017) and a total of 200 participants attended the conference. During the conference different research papers on urban water, sanitation and hygiene related topics were presented. During the conference, SEUHP did a presentation of a paper with a title SEUHP’s urban WASH experience and public WASH facilities situation in 28 cities/towns of Ethiopia.

Additionally, during the 14th International Urban Health Conference held at Coimbra, Portugal (September 26-29, 2017), SEUHP presented a poster on Urban Sanitation and Waste Management in Ethiopia: knowledge, perspectives, and practices among urban communities. Four people—one from FMOH, one from Addis Ababa RHB, and two from SEUHP participated in the conference.

The team had the chance to attend several pre-conference and conference events on different thematic areas such as: integrating work on the SDGs and the new urban agenda to improve health equity in cities; growing old in urban slums challenges to the health of older people living in the informal settlements; understanding and addressing demographic, epidemiological and societal changes in cities; urban governance and equity oriented policies; sanitation systems and urban health; cities as a driving force for integrating health in the new urban agenda; understanding the impact of economic crises on the populations mental health in urban areas; environmental-based public health risks and diseases; healthy urban planning, Measurements and metrics- data and research; urban health care system in cities; access, services, and quality; and environmental health and urban sustainability. Some of the lessons learned from the conference include: most of the conference agenda pronounced more of the developed settings; one of the papers that focused on governance shared an experience of a town in Portugal where individual SDG targets were assigned for each responsible sector to facilitate tracking of progresses; and the linkage between academia/research institutes and programs is very strong in many of the countries (like UK, Sweden, Australia) that shared their experiences.

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Sub IR 4.5: Implement emergency WASH interventions

In FY17, SEUHP gave priorities to five major emergency WASH response interventions including: build capacity of urban WASH Sector; construct/renovate improved sanitation and hygiene facilities; construct/repair water supply schemes/facilities; conduct health education and hygiene promotion in drought-affected communities; and conduct sanitation campaigns among communities affected by emergencies. The following key activities were accomplished in FY17.

Picture 12: SEUHP supported draught affected urban and pre-urban areas.

4.5.1 Build capacity of urban WASH sector actors for emergency preparedness and response

Organized trainings for WASH actors

With the aim of building the capacity of teachers and students on emergency WASH, training was organized for one day on basic and emergency WASH response and prevention and control of AWD for 245 individuals (38 females) including school principals, school WASH club members, and cluster education supervisors from SNNP (30), Amhara (92), Tigray (60) and Oromia (63) regions.

Tigray: In collaboration with town water office and town health offices, SEUHP gave technical and logistical support to conduct WASH trainings at Adigrat and Aalamata towns. Some of the activities performed include construction of pipe line extension and maintenance of hand dug well. WASH committee was established based on the water resource office/bureau rules and regulation. Selection of committee members was done by town water offices and municipalities. A total of 36 WASH committee members (Female= 17), 17 from Alamata (F=8) and 19 from Adigrat (F=9) attended the training that was organized using training manuals. The training was facilitated by technical experts from town water and health offices.

Amhara: In collaboration with town health and water offices, training was provided for 21 WASH committee and selected community members from Kombolcha town of 07 kebele and 05 kebele of Kemissie for 3 days. The WASH-committee training included hygiene, sanitation, management of water points by the community and role of WASH committee members. Finally WASH committee chairman, secretary, treasury and hygiene promoters were selected and discussion conducted on their roles and responsibilities.

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Emergency WASH (E-WASH) review meeting conducted

One day E-WASH quarterly review meetings were conducted for emergency taskforce members at town and kebele levels in Amhara (Kombolcha and Sekota), Oromia (Chiro), SNNP (Halaba) and Tigray (Adigrat and Alamata) Regions. A total of 291 individuals (124 females) from town and kebele administrations and sector offices (health, education, water supply and sewerage, women and child, youth, culture and tourism, trade and license, municipality-sanitation and beautification) participated in the review meetings. The review meeting aimed at monitoring the progress and status of E- WASH in the respective towns and Kebeles. Topics of discussion included major successes on prevention and control of communicable diseases, addressing the management of urban sanitation (solid and liquid waste); and identification of major bottlenecks with their possible solutions. Sector integration and functionality of the urban WASH committee were seriously taken into consideration.

Water quality test training conducted

As part of its partnership to contribute to efforts to ensure safe drinking water supply and prevention and control of water related health problems, SEUHP Oromia and SNNPR regional team conducted three-day training on water quality management for water utility offices, water technicians and technical staffs of Shashemene, Chiro and Hawassa towns. Topics covered included daily management of public water supply, quality monitoring and water treatment activities of specific towns. A total of 78 individuals (eight females) attended the training.

Sanitary material purchased and distributed to stabilization centers in Hallaba, Shashemene and Wolaita Sodo

In the reporting period, as one of the emergency WASH interventions, SNNPR SEUHP office distributed emergency WASH supplies (including sanitary materials) to stabilization centers in Wolayta Sodo, Halaba and Shashemene towns. The materials distributed include: laundry soap, water boiler, plastic basins, thermoses, electric stove, plastic bucket and plastic dish, blanket, and bed sheets.

Sensitization workshop conducted for WASH stakeholders

SNNPR: The regional SEUHP team conducted a one day sensitization workshop on WASH for religious leaders, community leaders, and community based organization representatives in Hawassa city. A total of 32 participants (16 females and 16 males) attended the workshop. The aim of the workshop was to raise the awareness of participants on WASH and enable them to transfer the knowledge to their followers/members in order to implement urban sanitation and waste management activities at household and community level; to create a link with UHE-ps in assisting the sanitation and waste management activities in their neighborhoods; and enable them to get prepared and respond before and during outbreaks particularly on AWD.

Addis Ababa: In order to strengthen the preparedness and response capacity of the city on emergency WASH including AWD, SEUHP in collaboration with the health bureau, organized a two-day workshop which brought together 21 participants (4 females) from stakeholders that are actively involved in the AWD outbreak response. The aim of the workshop was to design holistic strategies that improve the prevention, preparedness and response capacity of the city administration and its partners for AWD outbreaks on the basis of past experience and formulate AWD emergency response intervention toolkit. During the workshop, Emergency Preparedness and Response Plan/EPRP and community - 83 -

mobilization documents were developed. This document will clearly outline who will do what, how and when, and as a result, it will make the prevention, control and rehabilitation activities well organized and easier with the possible minimal attack rate and life loses.

Oromia: SEUHP Oromia regional team in collaboration with Negele town health office established an Emergency WASH Taskforce (ETF) composed of different stakeholders. SEUHP also organized training on emergency WASH response for 19 health workers (4 females) including UHE-ps. The taskforce members developed a draft work plan which will help them to prevent the occurrence of AWD and respond to any emergency promptly. UHE-ps and WASH TWG worked together to avert health related risk that may have happened following the natural disaster (flood) that occurred in Jimma town. The disaster affected about 152 HHs and about 800 populations. UHE-ps actively engaged on awareness creation to the affected community by distributing 700 brochures on AWD, identified and referred 17 individuals with health problems. Oromia SEUHP regional team continued to be active member of the AWD taskforce at Oromia regional health bureau level.

Amhara: Following the AWD outbreak that occurred in 57 Woredas in FY17, SEUHP facilitated a day long discussion workshop with religious leaders, regional, zonal and Woreda health professionals and partners focusing on preventive interventions including water source identification and chlorination, protection, latrine construction, and utilization and education on AWD. SEUHP provided a total of 55,000 brochures and 1,325 posters to the RHB to be distributed to the affected area for information dissemination.

Tigray: The RHB announced AWD outbreak in the region in the first week of June 2016. As part of the response activities SEUHP provided support logistically and in organizing sensitization and orientation at different city/town of the region

4.5.2 Construct/renovate improved water, sanitation, and hygiene facilities

In Tigray region, three Wagtech product water quality test kits were purchased and distributed to the Water offices of Adigrat, Sekota and Shasheme towns. Additionally, from each town, one water quality expert received training/orientation on how to use the advanced Pota Test Kit. The orientation was facilitated by SEUHP in collaboration with technical personnel from Wagtech in Addis Ababa.

Besides, in FY17, construction and/renovation of sanitation and hygiene facilities undertook in five towns; Adigrat and Alamata towns in Tigray Region and Sekota, Kombolcha and Kemessie towns in Amhara Region. The construction sites are grouped in three different lots. Hence, Lot-1 construction consists of construction works that are taking place at Sekota and Alamata towns while Lot-II construction includes constructions sites at Kemissie and Kombolcha towns and Lot-III construction comprises WASH construction works in Adigrat. The types of WASH facilities being implemented in each town and the progress of these constructions is presented in Annex 2.

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Picture 13: New public latrine with shower under construction

Picture 14: Public water point under construction with pipeline extension

4.5.3 Conduct health education and hygiene promotion in drought-affected communities

Public awareness is an important part of effective emergency risk reduction. Health extension programs in both urban and peri-urban areas promote hygiene and sanitation at household, community, and institutional levels. In this reporting period, SEUHP strengthened health education on scabies, cholera, and other infections through UHE-ps. SEUHP regional teams in Amhara, SNNP, and Oromia re-printed and distributed about 5,000 leaflets on proper hand washing and latrine use and 12,000 leaflets on scabies prevention to strengthen WASH promotion during global hand washing and toilet day. A total of 14,569 households were reached with key health messages. Besides, SEUHP SNNP regional team actively participated in regional public health emergency taskforce meetings led by Regional Health Bureau PHEM process owner.

4.5.4 Conducted sanitation campaigns among communities affected by emergencies

In FY17, sensitization workshops on WASH (proper management of solid and liquid waste disposal) were conducted in Amhara and SNNP regions for town administrators, WASH sector actors, UHE-ps, HEWs, supervisors, community representatives, religious leaders, C/THO and HC staff. SEUHP also supported the regular sanitation campaigns held in several towns in Amhara, Oromia, and SNNP regions. Oromia regional team printed school and community posters in Afan Oromo and Amharic in response to the request from the RHBs. Thirty thousand IEC materials, including school and community posters, were distributed during global hand washing day and the Ethiopian sanitation tradition of Hidar Sitatten celebration (a day of garbage collection and disposal by burning). In addition, 8,110 brochures, posters, and job aids prepared to educate community members and health workers on scabies were distributed to Sekota, Alamata, Kombolcha, and Kemissie towns.

Table 9 presents the summary of WASH related performance indicators for FY17 (annual and quarter four). Worth-mentioning here is that most of the WASH related indicators could be addressed more by household level surveys rather than administrative routine reporting. Hence, poor performance as indicated in the table doesn‘t mean the activities are not performed by the

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UHE-ps.

Table 9: Summary of WASH related performance indicators, Oct. 2016.-Sept.. 2017

Indicators FY17 FY17 FY17 FY17 FY17 FY17 Target Achieve Performanc Q4 Q4 Q4 ment e (%) Targe Achieve Perfor t ment mance (%) Number of workshops and 49 49 100.0 6 4 66.7 dissemination forums held to advocate for improved urban sanitation and management Number of functional urban 42 31 73.8 2 4 200.0 WASH management forum Number of households assisted 36633 37932 103.5 6042 5685 94.1 to construct basic latrine* Number of households 36424 51076 140.2 5839 14508 248.5 assisted/supported in gaining access to safe Liquid Waste/Grey Water Disposal Facility Number of households 38066 48212 126.7 9305 15706 168.8 assisted/supported with gaining access to proper Solid Waste Management Number of individuals trained to 3272 2851 87.1 58 307 529.3** implement improved sanitation and waste management methods (including IRT)

*Combining both improved and unimproved (30.6% for improved) ** Most of the training activities were performed during the fourth quarter.

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PART 1.5: OTHER KEY ACTIVITIES

1.5.1 SEUHP phase-in to two new towns in SNNPR

In the reporting period, SEUHP expanded project implementation to two additional towns in SNNP region. The two newly selected towns are Bodity from Wolyita Zonal Administration and Yirgalem from Sidama Zonal Administration. SEUHP now reaches all the 49 towns and cities planned for the project period. Some of the initial activities performed during the second quarter of FY17 include:

Sensitization workshop conducted: On this regard, sensitization meetings were conducted in Yirgalem and Bodity towns on Feb.27, 2017 and March 23, 2017 respectively. The aim of the sensitization meetings aimed to serve as a step-in for the program scale-up of SEUHP in the two additional towns. During the meetings, overview of SEUHP by focusing on the need of urban health program, lessons learned from the previous UHEP together with past three years implementation of SEUHP and goal, objectives, strategies of the program, key technical focus areas, key program elements, geographic coverage, expected SEUHP intermediate results, and major activities throughout the project life including the current updates were discussed. Consecutively, in case of Yirgalem town the revised UHEP implementation manual was presented by Regional Health Bureau Disease Prevention and Health Promotion Officer and feedback and comments were forwarded by the participants on the presentations and thorough discussions were made moderated by Mayor of the Yirgalem town administration.

The participants of this meeting in the target town included key people from SNNPR Regional Health Bureau, Sidama Zonal Health Department Disease Prevention and Health Promotion Head, the town administration health office, different sector offices in the towns and local NGOs. In total, 97 participants (47 females) attended the meeting for half a day (Yirgalem-52 and Bodity-45; table 13.) Apart from sensitizing the town on SEUHP, the sensitization occasion also served as rapport building with Yirgalem and Bodity town administration Mayors and health offices and sector offices in the towns.

Orientation of UHE-ps conducted: UHE-ps orientation meetings were organized for introducing and orienting the UHE-ps in the new towns on the background of the SEUHP and focus areas of the program. Besides, they were also given orientation on data collection tools and provided with formats to exercise data collection at household level in their respective catchment Kebeles. To this end, 63 UHE-ps and health workers (Yirgalem-28 & Bodity-35; 44 females) who are experts at town health offices and staff of health centers participated the orientation session. The orientation sessions took place on Feb. 28, 2017 at Yirgalem and on March 24 2017 at Bodity towns.

1.5.2 SEUHP hosted the USAID field visit in in SNNPR, Tigray and Oromia Regions

USAID’s Visit at Hawassa, SNNPR (first round visit): On October 17th, SEUHP hosted USAID Ethiopia team‘s visit at Hawassa city. The purpose was to observe SEUHP‘s implementation progress at the Alamura health center, and in two kebeles, Dume and Hiteta, served by it. UHE-ps from each kebele presented the major community activities. The visitors raised several issues and discussed them with the UHE-ps.

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Picture 15: USAID and JSI/SEUHP staffs visit at Alamura HC and Hitteta Kebele, Hawassa, SNNPR

On 18th of October, the USAID Ethiopia team and additional members visited the same health center and UHE-p office in Dume Kebele. They spoke with HC staff members about the health center‘s performance, its catchment areas. UHE-ps welcomed the guests and presented their activities, the catchment population profile, and the UHE-p packages. During the question and answer session, a women‘s health development army (HDA) representative spoke about her program and its work with UHE-ps.

Finally, the USAID Ethiopia team concluded the visit showing their appreciation and providing words of encouragement to the UHE-ps. They also acknowledged SEUHP‘s contributions and continued efforts to improve urban health at community level.

USAID’s Visit at Hawassa and Arba Minch, SNNPR (second round visit): SEUHP-SNNPR team hosted the visit of USAID officials which was a very successful visit at towns of Hawassa and Arbaminch. According to the USAID officials, the main purpose of the visit was to understand the urban health issues at the ground from the perspective of USAID support so as to formulate future directions and strategies for upcoming years. Therefore, it was mainly a learning and explorative visit. There was a one day pre-site-visit consultative meeting with USAID partners held at Hawassa which mainly focused on identifying key development challenges of the region.

In Hawassa (Gebeya Dar Kebele) the visit focused on UHE-ps activities and UHE-ps were able to explain their performances, achievements and challenges faced while they implement UHEP packages. The visit in Arbaminch town took place in Bere Kebele and it was mainly focused on visiting households and discussing with some of the community members. The team discussed on key health and development challenges of the community. In both towns, USAID delegates were able to learn and identify key challenges of the community and also appreciated the partnership opportunity that was created through SEUHP and expressed their readiness to collaborate with the program and also mentioned that SEUHP's priorities are well aligned with urban health needs and government's efforts in the region.

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Picture 16: Partial view of USAID officials visit at Hawassa, Gebaya-dar Kebele

USAID’s visit to Tigray region: a team from USAID visited one of SEUHP implementation site at Mekelle city. On November third, 2016 the planned USAID visit was conducted at Ayder sub city, Martha Kebelle. During the visit different events have been facilitated by UHE-ps and HCs representatives.

During the UHE-ps office level visit, accomplished activities related to UHEP were presented by UHE- ps of the catchment kebelles. To provide additional information about the UHEP implementation at community and household level, UHE-ps prepared 10-12 HDA leaders and 10-12 pregnant mothers the visitors had the chance to have conversation with the selected HDA leaders and pregnant mothers about the UHEP service in relation to SEUHP‘s supports. During the visit, Martha kebelle UHE-ps and community have presented different gifts and cultural music‘s to the visitors.

Picture 17: USAID and SEUHP Central Office team visit in Mekelle at Ayder sub-city

Finally the USAID visitors have acknowledged the contribution of the SEUHP project at community level and recommended to continue working with pregnant mothers and community level activities. Besides UHE-ps of Martha Kebelle UHE-ps and Semien Health center received materials and equipment to support their day-to-day SEUHP related activities with including: two computers, UHEP kits which have BP apparatus (Manual and Digital), Thermometers, Umbrellas, UHE-ps Bags and other related materials).

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USAID’s visit to Ambo and Bishoftu towns, Oromia Region: In this reporting period, SEUHP successfully organized site visits for USAID experts in Amhara (Bahir Dar town), Oromia (Ambo town), and Tigray (Mekelle town) regions. in addition to participating in partner forums organized in the respective regions as part of USAID‘s next five year planning process. SEUHP Oromia regional team also facilitated the field visit to Bishoftu for a high level delegation from USAID global office in Washington, DC. The team paid a visit to Cheleleka health center. The Primary Health Care Director of the HC made a brief presentation on the successes and challenges of the health center while the urban health extension professionals made a presentation on their catchment achievements. The team visited the delivery, PNC and EPI units of the HC. The visiting team appreciated the efforts of the HC and the UHEP.

Picture 18: USAID team with Bishoftu Cheleleki Health Center staffs and SEUHP team

1.5.3 SEUHP's exhibition at the 18th ARM of the FMOH

The 18th ARM conference took place from October 19th – 21st at the Millennium Conference Center in Hawassa. Health sector leaders, public health professionals, academic and research institutions, NGOs, and stakeholders from across the country attended. During the event, various reports, studies, challenges, and successes from the Ethiopian health sector were presented and discussed. In addition to these sessions, FMOH and partners organized an exhibition at which Picture 19: Higher officials and other participants visiting SEUHP work was displayed. SEUHP booth at the 18th ARM, Hawassa.

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1.5.4 Revitalization of HEP

Currently the urban, rural and pastoral health extension program implementation is facing many challenges. As part of addressing these challenges, the FMOH planned to conduct rapid assessment (RA) on the implementation of the Health Extension Program (HEP) in order to understand the current landscape of the HEP and develop a policy- brief which helps the policy makers pass informed decisions for the revitalization of the HEP.

To contribute to this endeavor, SEUHP is engaged in a number of undertakings during the reporting quarter:

 Participated in the HEP- revitalization taskforce meetings at the office of the state Minister, FMOH.  Developed a proposal for conducting rapid assessment on UHEP in seven regions.  Developed rapid assessment data collection tools.  Facilitated use of the proceeding of the national Urban Health Conference as input.  Collected assessment data from the primary source (respondents of RHBs, THOs, HCs, Kebeles, and community).  Synthesized data related to the HEP from secondary sources (different research papers, reports of supportive supervision findings, and proceeding of Urban Health Conference)  Compiled primary and secondary data.

1.5.5 Attended training on urban sanitation

During this reporting period, the CC Bahir Dar participated in a three-days training on Urban Sanitation (Faecal Sludge Management) in Ethiopia organized by Water Aid in collaboration with Yorkshire Water Utility and Leeds University. The main objectives of the training were: to further develop the Shit Flow Diagram (SFD) approach a tool used to readily understand and communicate how excreta 'flow' through a city or town, develop a robust approach to estimating faecal flows, providing easy-to-use tools to support cities and towns to estimate faecal flows and creating a dataset which allows a fuller analysis of the state of sanitation in a wider range of cities.

1.5.6 Participated in an initiative led by the Prime Minister’s office to improve WASH in Addis Ababa

The Prime Minister‘s office launched an initiative to enhance program implementation capacity in Addis Ababa on selected agendas including WASH. In this regard a team of government experts led by officials delegate from the Prime Minister‘s office developed action plan in June 2017. SEUHP was invited to make presentation and share experience on WASH to the team. Based on this request SEUHP‘s Senior Environmental Health Adviser and Addis Ababa regional manager presented on the situation of WASH in Addis Ababa, major gaps, SEUHP‘s role and what should be done in the future to improve WASH in the capital city. The presentation and recommendations were well taken by the team and they appreciated SEUHP‘s support and they promised to incorporate the recommendations into the plan that will be submitted to the Prime Minister‘s office.

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PART 1.6: SEUHP COMMUNICATION AND DOCUMENTATION-RELATED KEY ACTIVITIES AND ACCOMPLISHMENTS

SEUHP has a comprehensive strategy for communicating ongoing program activities, urban health information, and outreach efforts. In line with this strategy, the following key activities were implemented during the reporting period.

1.6.1 Documentation of SEUHP’s technical support to UHE-ps

SEUHP documented its activities, achievements, challenges, and lessons. It disseminates them to SEUHP staff, stakeholders, and partners to encourage learning and to validate program achievements.

Documentation of best practices and success stories has been an unceasing task. In FY17, SEUHP documented numbers of stories about beneficiaries, including community members, UHE-ps, UHE-p supervisors, and city/town offices in all regions. Selected stories have been edited and sent to USAID, program teams, and governmental partners. As usual, various events, workshops, and other program activities were properly documented during the quarter.

1.6.2 Lead knowledge management activities

As SEUHP is approaching its final year of implementation, learning from years of program implementation need to be identified and shared among urban health stakeholders. As part of its knowledge management initiative, SEUHP has conducted the following activities.

 Digitization (e-Copies) of all SEUHP related documents: SEUHP has introduced and collaboratively produced many technical documents such as research papers, program briefs, tools, job aids, training manuals, etc. that facilitated UHEP implementation at federal, regional and city/town levels. In order to ensure the easy accessibility and sustainable use of these resources, SEUHP is undertaking the task of digitizing all technical documents and share with FMOH, RHBs, C/THOs, HCs, and UHE-ps. In FY17, QIV, the various documents that SEUHP has produced across its program implementation are mapped and gathered. In the coming quarters, SEUHP will systematically organize and share the documents with stakeholders.

 Strengthen program documentation and sharing of lessons learned: The experience and knowledge that SEUHP staff has accumulated over the course of the project implementation must be properly identified, documented, and systematically disseminated for continuous learning to take place. In FY17, SEUHP has strengthened its program documentation efforts and documented LMG, CHIS and PHCU activities of SEUHP.

 Utilize website developed by AAU/SPH as one of resources sharing platform: AAU/SPH has developed a website that will serve as a pool for resources on Ethiopia‘s urban health such as studies rules and regulations and other resources. With the aim of using this website as one platform to share its activities and contribution with the general public, materials and resources produced under SEUHP are organized and loaded on the site. In

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addition, support has been provided in the general website layout designing, web content development and organizing process.

1.6.3 Summary of the SEUHP’s FY16 annual report prepared

SEUHP‘s program activity progress, challenges, and lessons have been captured in the annual report. A five-page summary that highlights key achievements has been prepared for SEUHP stakeholders (donors and governmental partners).

1.6.4 Support media engagement activities

SEUHP recognizes that media can support its objective of improving the well-being of the urban dwellers in Ethiopia. Media can also support promote new approaches in the Ethiopian urban health system.

During the reporting quarter, SEUHP executed activities that enhanced media engagement at regional and national levels and serve as an urban health resource for media professionals. Hence, SEUHP established partnership with the media; and organized workshops to build the capacity of the regional health bureau‘s communication team, and media professionals; and supported the designing a media engagement plan and to ensure on execution and impact.

To enhance this, a brief guidance document on media engagement guide was prepared. To this end, a full page report on urban health was published at the Ethiopian Reporter Newspaper-Amharic headlined, ―Urban health should be a national agenda that requires due attention,‖ with an interview from SEUHP COP Hibret Alemu. Bisrat FM 101.1 and Sheger FM 102.1 radio stations covered the national workshop organized by SEUHP and Diageo on law enforcement trends on under-age drinking in Ethiopia and other urban health issues.

1.6.5 Production of Documentary with EBS

Following the first national urban health conference, SEUHP has been working to produce documentary films that help the society to know about urban health and its different segments. According to a bid process; EBS has been selected for the production and transmission of the documentaries. However, due to different reasons, the production and transmission has been taking too long. Taking this into consideration, SEUHP has assigned the communication team to take a lead and work closely with EBS to have the documentaries ready shortly. Accordingly, the communication‘s team has been communicating with respective people that need to be included in the interview, facilitated the interviews and to organized interview schedules. As per the amended agreement, SEUHP is expected to have two episodes of WASH documentaries by the 30th of October and documentaries on Urbanization and UHEP to be finalized by the 30th of November, 2017.

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Branding and logo management simplifies communication between JSI, donors, government, and local implementing partners. In an effort to create a strong identity for SEUHP and enhance recognition of USAID‘s contributions, SEUHP technical documents and communication materials including nursing bags, fliers, brochures, and posters for AWD were marked in compliance with the branding and marking protocol.

1.6.7 Newsletter produced

Producing a quarterly newsletter is part of SEUHP‘s effort to facilitate collaboration among the important stakeholders in the urban health arena. SEUHP has disseminated two issues of newsletters and finalized production of a special edition issue which showcases program success stories, updates, important lessons learned and best practices. 1.6.8 Press releases

Press releases were written to promote the program‘s identity, role, and contribution among a wider audience. Press releases and speeches for various events, such as workshops and visits by donor officials, were prepared.

1.6.9 Editing and formatting of various materials produced by SEUHP: In support of the technical team‘s effort, various documents such as PPT and poster presentations, reports, and research briefs etc have been edited and standardized.

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PART 1.7: OPERATIONS AND FINANCE: KEY ACTIVITIES AND ACCOMPLISHMENTS

1.7.1 Administration

The following is a detailed description of key SEUHP operations and finance-related activities during the year ended FY17.

1.7.2 Administration Implementation of the FY17 work plan: The operations team supported activities to accelerate the technical implementation of the program. Key areas that the team supported include the following:

(1) Administrative and logistical support for various national workshops and trainings including but not limited to the launch of the IRT pilot testing from October 2-6, 2016 at Hawassa Health Science College; leadership, management, and governance training to SEUHP staff from October 19– 23,2016, National Master TOT on Competency-Based Urban IRT from November 23-30, 2016 at Adama; consultative workshops organized by the Diageo team on enforcement of the legal alcohol purchase age on November 30, 2016; workshops on script review and validation of the radio serial drama from December 17-18, 2016; supported 23 trainings for Oromia and Addis Ababa regional offices like HIV training, Quality Improvement training, Review meeting, Leadership Management Governance training, IRT TOT and Media engagement review meeting, Coaching training and CHIS and PHCU reform orientation training.

(2) Facilitated and supported operations, finance and logistics for the organization of the National Urban Health Conference held from April –3-4, 2017. (3) Guidance on FY17 annual work plan finalization by organizing series of consultations and provide support in tracking the budget utilization. (4) Maintained staff safety by introducing security measures while they travel and implement their day- to-day activities. (5) Attend the UNDSS meeting every Friday to update/inform the whole staff in order to avoid tense and insecure areas as they implement their day-to-day activities.

Fleet/vehicle management: Due to internet connectivity problems in the country, the use of GPS units was seriously hindered and SEUHP had difficulty monitoring the movement of its vehicles. However, the internet connectivity problem was resolved in the second quarter and started to use the GPS data for tracking the movement of vehicles. JSI SEUHP needs additional vehicles to manage overall program implementation in the country. SEUHP received two disposed vehicles from the Management Science for Health project (MSH SIAPS with cooperative agreement no. AID-OAA-A-11- 00021). The required documentation from USAID and MSH were finalized in the FY 2017. The vehicles are ready to be dispatched to SEUHP‘s two regional offices (Amhara and Harar/Deri Dawa in order to facilitate the implementation of the program. SEUHP procured fuel sensors for the vehicles in order to monitor the fuel utilization of the vehicles and to generate an automated report for fuel refill. The vehicles annual inspection, vehicle insurance and service is up to date.

Procurement: The following are major procurement and printing related activities in the reporting period:

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(1) Printing materials – more than 34,345 training manuals, banners, posters, brochures, job aids, and related materials were printed and distributed for use by UHE-ps and their supervisors. Printing of 1,500 copies of IRT training module, 1,317 referral slips, 1,367 copies of service data recording tool, 31,600 CHIS cards with 1,207 stickers; 5,900 LMG trainers and participants manual, 90 copies of the baseline assessment for the CHIS tools, 3,060 pcs of CHIS TOT manual, 250pcs of Amhara Strategic plan booklet, 76,695pcs of CHIS cards in different colors, 5,000pcs of FHT household cards, 200pcs of FHT weekly performance note book and 6pcs of photo print were printed and distributed for use by UHE-ps and their supervisors.

(2) Renting vehicles – SEUHP rented minibuses and coaster buses to transport staff to various events and workshops, supportive supervision, and field visits.

(3) Furniture, computers, and supplies - Office furniture and computers were procured for newly hired staff at central, Addis Ababa, and Oromia offices. Stationery and other small items(printer fuse, laptop battery, laptop adaptor, screen for laptop, photo frames and the like) were procured and distributed to staff. Network items (like Cisco Router 1941, D-link network switch 8 port, TP-link access point, 450MB/sec, Network rack 6U, UTP cable cat 6, RJ-45 connector and power extension) were procured for Tigray and Amhara regional offices. Office furniture and computers were procured for newly hired staff at the central office, Addis Ababa and Oromia offices. Office stationery and other related items were procured and distributed to the staff.

(4) Equipment for program use - Three water quality test kits were purchased with USAID approval because they cost more than USD 5,000.00 per unit cost limit. The equipment will be used to monitor drinking water quality to ensure safety. JSI SEUHP distributed UHE-p nursing bags (2,300 pcs), umbrellas (2,300 pcs), and thermometers (2,300 pcs). A total of 590 blood pressure monitors were procured and are being distributed with the nursing bags. JSI SEUHP received and distributed the second batch of the BP apparatus (1,396pcs) to the SEUHP implementation sites and will expect to receive the final batch by the next reporting period. JSI SEUHP procured 310 UHEP bags for the Family Health Team and tablets for electronic data processing during the current reporting period. Moreover, SEUHP procured ultrasound with its printer model CT 5500 with 10inch monitor one Health Center at Addis Ababa.

(5) Procurement of service to air the radio magazine program: All regional offices worked with their regional media agencies to air the radio magazine program.

(6) Construction: SEUHP started construction of hand-dug wells, public latrines, and shower facilities in three geographic areas: lot 1- Sekota and Alamat, lot 2- Kombolcha and Kemissie and lot 3-Adigrat.

All procurements were based on JSI standard operational policies and procedures and USAID rules and regulations.

Safety and security: SEUHP updated its staff safety and security information of the country every week and holds regular discussions with the security agency of the SEUHP office to strengthen the office security system.

Meeting/Communication with USAID: SEUHP‘s COP met with the project‘s AOR to discuss major achievements of FY 2016 and key activities planned for FY 2017.

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SEUHP submitted the FY 2016 annual progress report and its summary; the FY 2017 annual work plan; request to procure water quality test equipment; the SEUHP quarterly accrual report; and quarterly SF425.

Safety and security: JSI-SEUHP updates its staff on safety and security every week and holds regular discussions with the security agency of the SEUHP office with the aim of strengthening the office security system.

Meeting/Communication with USAID: SEUHP‘s COP and management team met with the project‘s AOR (Dr Helina), Mr. Eshete, and Dr Yosef to discuss major achievements of FY2017‘s Semi-Annual Progress report and key activities planned for the third quarter of FY 2017.

During the reporting period, JSI SEUHP submitted; SEUHP FY 2017 Semi Annual Progress Reports; SEUHP FY 2016 VAT report; SEUHP quarterly Accrual Report, SEUHP obligation increase letter, and SEUHP Quarterly SF425 to USAID and no cost extension request. SEUHP also received three notifications from USAID; mechanism specific expenditure analysis data extraction, agreement officer and point of contact at USAID and Modification 11 for the incremental funding. Moreover, SEUHP submitted a no cost extension request to USAID and waiting to receive an approval.

Human resources

Staff benefits: annual employees‘ life and medical insurance agreements were renewed.

Performance Evaluation: annual performance reviews were conducted for 53 staff.

Electronic time sheet: JSI is transitioning from paper-based to electronic timesheets.

New staff: There were new staff members that joined JSI SEUHP in this reporting period: Procurement and Logistics Manager; Program Officer for Tigray Regional Office; Primary Health Care Specialist for Addis Ababa; Driver for Addis Ababa, Amhara and Harrer; Cluster Coordinator for Alamata; WASH Specialists for Amhara, Oromia and SNNP Regional Offices, Office Assistant for Hawassa; Cluster coordinator for Addis Ababa; Communication Specialist, Data encoders for KMC (six) , temporary driver for Hawassa regional office. A central office driver is assigned as Logistics Officer at central office to strengthen logistics management capacity.

Consultant Hire: JSI hired consultants for the following positions; five FMoH Senior Technical Assistants, one event coordinator for the National Urban Health Conference, One WASH Business Development consultant, one artist and one song producer, one Qualitative Research and Report writer and KMC Research Assistants.

Termination of employees: During the FY 2017 reporting period, one senior technical assistant hired to FMOH and two Diageo staff members were terminated due to personal reasons and project closeout, respectively. SEUHP‘s operations assistant was also terminated due to unjustified absence for her duty station. SEUHP‘s Grant and Compliance Manager resigned.

1.7.3 Finance SEUHP Finance Unit: The JSI SEUHP finance unit supports the program staff in handling all payments in a timely manner and according to JSI‘s and USAID financial rules and regulations.

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Revision of work plan with the FY 2017 budget preparation: The SEUHP finance team and operations director worked closely on the FY 2017 work plan preparation at regional and central office levels.

Expenditure analysis report: SEUHP uploaded the expenditure analysis report on the promis database on November 11, 2016. Currently, SEUHP is working on the year expenditure analysis report and will be uploaded the FY 2017 EA on November 03, 2017.

Regional finance: The SEUHP finance team reviewed and gave feedback on the financial vouchers to the regional finance and administrative personnel every month to ensure that the JSI-SEUHP and USAID rules and regulation are followed.

1.7.4 Partnership

AAU: AAU SPH and SEUHP signed a Fixed Award Amount contract starting from March 01, 2017.

EDA: SEUHP conducted a meeting with EDA leadership to identify the strategic focus areas of the FY 2017. A contract modification is signed with EDA in the reporting period.

As part of the JSI/SEUHP‘s public private partnership portfolio, SEUHP worked with Diageo Global Company subsidiary Meta Abo Factory within the Corporate Social Responsibility scheme from December4, 2015 to December 3, 2016. SEUHP reached 45,687 youths via school, youth centers, and outreach activities. Finally SEUHP successfully completed and closed out the project as of December 2016 by organizing a final workshop to enforce the legal alcohol purchasing age.

Harvard T. H. CHAN School of Public Health: SEUHP is collaborating with World Health Organization (WHO), Harvard School of Public Health, and Addis Ababa University on implementation research about scale-up of kangaroo mother care in Addis Ababa, Adama, and Zeway. Even if the KMC project terminated on September 22, 2017, the Harvard School of Public Health granted a no cost extension for SEUHP to finalize the project till December 31, 2017.

1.7.5 Compliance

Monthly financial vouchers were inspected and checked at the Central office, Amhara, SNNP, and Tigray regional offices and Emmanuel Development Association. As part of the day-to-day internal controls, the finance team supported the program by providing spot checking of petty cash, vehicle logs, timesheets, etc., to check for compliance with JSI, USAID, and GOE regulations. There was no discrepancy observed on the GPS data and the vehicle log sheet. All procurements were regularly inspected for compliance. Visual compliance was taken for new hired staff and vendors. The annual visual compliance report was submitted to JSI HQ for documentation.

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1.8: DATA QUALITY ISSUES DURING THE REPORTING PERIOD SEUHP routinely collects data through the regular reporting system for monitoring purpose and it is used to inform program decisions. Hence the issue of data quality is of huge importance. SEUHP has adapted the PEPFAR/USAID Data Quality Assessment (DQA) tool and prepared a data quality management plan to guide rigorous checks on data quality as well as on the process of data management at the SEUHP regional offices. In FY17, SEUHP planned to conduct internal rigorous data quality checks at regional offices at least twice in a year using the DQA tool and to ensure proper documentation of the findings from the assessment.

In FY17, SEUHP teams have been performing the following activities with the aim of improving the quality of the program data:

National level MER Team Meeting conducted: During the first quarter of this reporting period, SEUHP CO organized two-days MER Team meeting with the aim of sharing ideas from FY16‘s quarterly and annual performance reports and the FY16 internal DQA exercise and the lessons learned that can be used as inputs in shaping FY17 plan and implementation. During the meeting, there were slide presentations regarding data quality issues observed from the FY16 annual report and the findings from the internal DQA. Some of the factors contributing for poor data quality were: over and under- reporting, difficulty of measuring some of the indicators e.g. health education and WASH related indicators, poor documentation, double counts due to the database problems, and different reporting approaches in terms of details like age-sex disaggregation among others.

One of the data quality issues raised and discussed during the MER Team meeting was untimely/delayed reporting from the field to the data centers. The existing data collection system follows a long process due to the scattered nature of towns and high number of UHE-ps. Reports are being sent through buses, DHL, or through individuals traveling to the regional capitals. Because of this, there is much delayed data entry and carryover of some monthly activities. One of the best approaches proposed by meeting participants is to use the government‘s reporting system by having one customized reporting template that accommodates indicators needed for government reporting consumption. While we are waiting for the introduction of the UCHIS, the team has agreed to make sure every data reaches at regional office level between the 20th and 25th of the reporting month. Finally, during the meeting, each M&E Advisor and regional managers who were present during the meeting developed plan of action.

Regular data quality checks conducted: In this reporting quarter, SEUHP regional teams have been also providing technical support to C/THOs to ensure the quality (completeness, consistency, timeliness, and reliability) of data recorded using SDRT at UHE-p level. To this effect, SEUHP regional teams have conducted regular data quality checks during data collection and supportive supervision visits from UHE- ps and their supervisors. Data completeness, accuracy and consistency were checked using the developed grading system in the supportive supervision checklist.

In the reporting period, incomplete records and lack of consistency among some data elements were identified as major gaps. Measures to address these data quality issues, including on-site mentoring and

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cleaning of recorded data, were done and the incomplete and incorrectly filled formats were selected from the submitted records (for data entry) and returned to the UHE-ps for corrective measures. SNNPR SEUHP team set a mechanism for UHE-ps to get data recording support from SEUHP cluster coordinators. On top of these, the regional SEUHP team discussed and proposed new initiative that includes assigning one of UHE-ps as a data quality focal person at UHE-ps office level. To alleviate problems related to delay in reporting, regional teams have been doing different activities. On this regard, AA SEUHP Regional Office devised a mechanism by organizing regular monthly supervisors‘ meetings whereby every participant comes with monthly data to the meeting. This has helped to get data without delay and to avoid carryovers in data entry.

Bi-annual Data Quality Assessment conducted: In FY17, SEUHP CO conducted two rounds of DQAs during the second and fourth quarters in all SEUHP implementation regions. SEUHP CO facilitated the data quality assessments among SEUHP regional offices by swapping regional M&E Advisor between regions so that the M&E Advisors can conduct the assessment simultaneously (with no chance for delay of ding the DQA) across all the SEUHP supported regions. The swapping approach created an opportunity to share experiences between regional M&E Advisors including other SEUHP staffs and UHE-ps.

The objectives of the DQAs were:

 To assess the completeness and accuracy of records at the UHE-ps level;  To assess the consistency of data collected from UHE-ps with the transcribed data in to the electronic database and examine its consistency with the report generated;  To assess office level documentation;  To assess whether the action points of the previous DQA were translated into action or not; and  To provide feedback and improve the quality of data at all levels.

The five core indicators selected for the DQA were:

 Number of individuals who were referred to facility for access to services ( CA/8);  Number of individuals who received a follow up visit from UHE-ps on TB, ART, and ANC (N/);  Number of individuals who received HTC and received their test result (PEPFAR HCT_TST CA/23-1).  Number of defaulters identified and linked to health facilities for continuity of services (CA/10)  Number of individuals reached with direct services from UHE-ps; indicator (CA/23)

Besides the above indicators, documentation was assessed at SEUHP regional office and UHE-ps office level. In the DQA, 7 SEUHP regional offices and 36 Kebeles (selected randomly) were covered. The DQA covered the first quarter and third quarter periods of FY17. Data collection was done electronically using ODK and this helped real-time monitoring of the field level activities. Though it was the first time the electronic data collection was used, it was a good learning opportunity to the M&E Advisors and others who were involved in the DQA exercise. At the end of the DQA exercise, each region has developed action points that will be fixed in the coming implementation periods before the next round of the DQA.

Though there were several strengths of the data quality status of the program, we found it better to indicate the summary of major areas of improvement identified through the DQA so that they can get attention at every level: - 100 -

 In some areas, the print copy of HTC data was mixed up with individual service data recording tools that made the data quality check exercise cumbersome. This is because of archiving problem that must not need much effort for it to be corrected.  In all of the regions, there is a problem in coding target groups in HTC registers. Most of the cases were coded as 99 i.e., others (more pronounced in Addis Ababa and Oromia).  In some areas, number of defaulters traced and those on treatment showed significant difference between recounted and reported data;  Poor recording despite a number of services were being provided.  Lack of completeness and consistency on HTC registers (SNNPR);  Poor accuracy and lack of completeness in few areas that were covered by the DQA.  At Kebele, sub-City, and HC levels: UHE-ps are providing multiple services though not each service is recorded on daily service recording tool and not reported in regular reports (under- reporting is common);  Common to all regions, some of the UHE-ps are not capturing the target groups correctly in their HTC register.  Referral feedbacks were not updated on individual service data recording tools on regular basis  The presence of untrained UHE-ps who are using the service data recording tools without full understanding of the tools is affecting the quality of data.  Some of the regions didn‘t fix the major action points identified during the previous (July 2016) DQA.  Poor referral feedback and documentation mechanisms due to absence of referral focal person which was found effective in some other regions like SNNP.  In some areas, LQAS is not done routinely.

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PART 1.9: CHALLENGES AND PLANS TO OVERCOME THEM DURING THE REPORTING PERIOD CHALLENGES PROPOSED SOLUTIONS

Competing government priorities, hindered Re-aligning activities/planned as needed. implementation of our plan.

Delay of the urban CHIS implementation. SEUHP is working with FMOH to finalize the piloting of the urban CHIS and its scale-up.

Government sector offices priorities, mainly Repeated discussions with C/THOs to related to ongoing political (leadership and accomplished the planned activities governance) reform following the insecurity that happened last year affected many planned activities including major construction activities related to WASH.

Insecurity at Dilla town significantly affected the Through frequent discussion with Dilla THO it team‘s ability to execute all activities planned for was possible to perform some of the program the first quarter. activities.

High turnover of trained health workers (at health Replacing new member to QI team with brief facility and health office levels), particularly the orientation on QI activities. quality improvement team members and chairpersons. Many UHE-ps lack HIV counseling skills. Link UHE-ps with HC HIV counselors for on-the- job orientation.

Restricted movements in some towns in Amhara We were attentive for frequent security updates and Or Omiya regions delayed implementation of not to miss opportunities of movements. As of some activities. the third quarter, it may not be a problem since the State of Emergency related to the movement restriction has been lifted.

Delay of the urban CHIS that in turn affects Piloting of CHIS is undertaking and SEUHP is ownership of the existing SDR tools playing great role on this regard.

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PART 1.10 MAJOR ACTIVITIES PLANNED IN THE NEXT REPORTING PERIOD The following summarizes major SEUHP activities planned for Q1 of FY178 in line with SEUHP's intermediate results.

IR 1: IMPROVED QUALITY OF COMMUNITY‐LEVEL URBAN HEALTH SERVICES

Sub IR1.1: Improved knowledge, skills, and motivation of UHE-ps 1.1.1Organize national level Master TOT of second round Urban IRT (MCD, NCD, and Basic first Aid) 1.1.2 Support FMOH and RHB in implementing UHEP Optimization process 1.2 Sub IR 1.2: Improved UHE‐ps' access to standard health service delivery packages and service standard manuals 1.2.1 Maximize the utilization of UHE_P implementation manual and reference tool kits by UHE-ps, HC, CTHO, and RHBs Sub IR 1.3: Improved implementation of QI initiatives 1.3.1 Advance the implementation of QII in 21 selected sites 1.3.2 Work with the FMOH and RHBs to Institutionalize QI Initiatives (QIIs) Sub IR 1.4: Improved referral and linkages between UHE‐ps and facilities Sub-IR 1.7: Increased access, coverage, and utilization of high-impact MNCH, FP, and RH services 1.7.1 Enable the UHE-ps to provide MNCH services Sub IR 1.8 Increase access to FP/RH and AYRH services Sub IR 1.9 Implement Urban PHCU Reform in 9 health centers

IR2: INCREASED DEMAND FOR FACILITY-LEVEL URBAN HEALTH SERVICES

Sub-IR 2.1 Implement Strategically Designed Behavior Change Communication Interventions Sub IR 2.1.1 Expand Access to and Utilization of Information, Education and Communication (IEC) Materials and Tools focusing on Urban Health Priorities Sub IR 2.2. Produce and air radio programs to promote and model key RMNCH, HIV/AIDS , TB and WASH related behaviors

IR 3: STRENGTHENED REGIONAL PLATFORMS FOR IMPROVED IMPLEMENTATION OF THE NATIONAL URBAN HEALTH STRATEGY

Sub-IR 3.1: Improved institutional and managerial capacity of urban health units at RHBs, ZHDs, and C/THOs 3.1.2 Conduct leadership, management and governance capacity enhancement for C/THO, HC staffs - link with OCA 3.1.3 Conduct C/TCHO level comprehensive training workshop to ensure Institutionalization of the Practices in to GOE‘s Health System 3.1.5 Support RHBs to conduct integrated supportive in urban areas Sub IR3.2 Improved urban health data collection, analysis, and use

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3.2.2 Support at scale Implementation of the Urban Community Health Information System in SEUHP Target Cities/Towns 3.2.6 Generate Evidence on Urban Health and the SEUHP Sub IR 3.3 Knowledge management: Documentation and sharing of program lessons to governmental stakeholders 3.3.2 Strengthen program documentation and sharing of lessons learned

IR 4: IMPROVED SECTORAL CONVERGENCE FOR URBAN SANITATION AND WASTE MANAGEMENT

Sub IR 4.1: Increased WASH Governance and Management Capacity at all Levels 4.1.1 Implementation of IUSHS started in at least five regions/city administrations 4.1.2 Support to sustain and institutionalize already established WASH Platforms in selected 13 cities/towns 4.2.3 Promote Public-Private Partnership (PPP) Model on Urban Sanitation and Waste Management 4.2.4 Finalize the construction and management of model public latrines

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ANNEXURE

Annex I: Success Story

Annex 1a: Success story-1

STEADY SUPPORT TO ACCOMPLISH THE GOAL OF AIDS FREE GENERATION Mastewal Molla, 35, lives in Tana Sub City, Bahir Dar town of the Amhara Regional State. Mastewal got married while she was 20 years old. When Mastewal and her husband tied the knot, they didn‘t get tested and hence, they had no idea about their HIV status. ―I got married while I was still a virgin. How can I be curious about my HIV status? I was very sure that I was negative,‖ said Mastewal. She added, ―It was very much difficult to accept my result and live with it. I didn‘t know any other person than my husband; and for me, being concerned about HIV was unimaginable.‖ In their 15 years of marriage, Mastewal and her husband gave birth to three children; a son and fraternal twins (a boy and a girl). It was when she was pregnant with the twins that Rahel Franco, UHE-p in Bahir Dar visited Mastewal‘s house; as it‘s in her catchment area. After checking Mastewal‘s health status and identifying her pregnancy, Rahel referred her to Bahir Dar Health Center for antenatal care service. ―I knew about her HIV status while I checked her at her house and that‘s why I referred her to the Health Center. When I told her about her status, she became very angry and didn‘t want to accept the result,‖ said Rahel. However, Rahel continued her support and counseling to Mastewal and her husband to go to the Health Center and get proper medical service. She also advised them to start ART. That was when Mastewal‘s husband told Rahel that he knew about his status and was already on ART without disclosing his Picture 20: Rahel, Urban health extension professional, follow status to his wife. on the health status of Mastewal, HIV positive mother including ―When I know that my husband had her nutritional status.

hidden his status from me, I was very sad. That also raised a disagreement between us and we were living separately for some time. Nevertheless, Rahel continued her consultation and advised us to live a positive life. And we have lived together till his death,‖ explained Mastewal.

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Now, because of the continuous support and counseling that Rahel provided Mastewal, she gave birth to HIV free children (twins). ―Rahel continuously advised me to follow the kangaroo care system and I do that. Thanks to her, now the twins are very well and growing. She follows my nutrition and gives me advise on how to care my babies, how to protect them from infections, how to keep our hygiene, how to feed them and make them get tested for HIV every three months,‖ said Mastewal. Rahel is one of the 335 UHE-ps in Bahir Dar Town. She serves 722 households in her catchment area. She is one of the UHE-ps who received different trainings on Urban Health that was provided by the RHB in collaboration with SEHUP, a program implemented by JSI through a fund raised by USAID.

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Annex 1b: Best practice-2

MAINTAINING CLEANNESS TO AVOID DISEASES:

LESSON FROM KETENA 08 NEIGHBORHOOD

Mimi Mengesha and her 11 neighbors live in a compound located in Arada Sub City at a neighborhood called Ketena 8 which is located behind Semien Hotel. One has to walk through the narrow foot path to get in to Mimi‘s and her neighbor‘s houses. The left side of the path is fenced by small rocks to protect the eye catchy plants.

Nevertheless, as explained by Mimi, the compound was very different a year ago. ―It was very dirty. Even people from outside come and use the compound as open defecation space because it was very much unclean. And we were ashamed to bring guests and people to our compound,‖ explained Mimi.

There are 12 households in the compound and there was only one communal latrine. This made the cleaning Picture: The newly planted floras by the entrance of and the usage very difficult. Mimi added, ―Nobody was the compound responsible in cleaning the toilet. Besides, I think people preferred to use the outside to avoid waiting to use the toilet. In addition, the bad smell caused different illness After noticing the problem, Sr. Mulumebet Negash, such as flu and diarrhea on us and our children.‖ Health Extension Professional, and her supervisor Letebrhan started discussion with the households to That was when Sr. Letebrehan Girmay, a UHE-p utilize the toilet. The discussion let to establish a supervisor at Wereda 5 Health Center visited the committee that collects money every month from each neighborhood. ―Right after I saw the neighborhood I household that uses the toilet. To construct the toilet, decided that we needed to intervene. Hence, I assigned the supervisor together with the UHE-p communicated Sr. Mulumebet, UHE-p to work on it,‖ said Sr. the Woreda Health Office. Their question was accepted Letebrehan. and the toilet was constructed with a cost shared by the Woreda and the collected money from the households. ―Thinking about changing the place into such a clean area was absurd by that time. However, that was not Mimi said, ―Before constructing the toilet, we had to the only problem. Whenever the UHE-p came here to clean up the area and the compound in general. During have a discussion with us, she couldn‘t find us as most of that time both the UHE- p and her supervisor were with us were at work. But she didn‘t give up and she started us and helped us in the cleaning.‖ coming here after working hours. Even then, since it was very smelly, we either had to go outside or go into one The newly constructed toilet has eight holes in eight of the houses to have our discussion. Thanks to her, we separated rooms. Some of the families share one room now have a clean toilet which everyone responsibly whereas the others have their own separate toilet. The takes care of,‖ explained Mimi. division is based on the number of family member each household has.

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There is a schedule to clean the toilet and each household ―Actually, it was very difficult to make this happen. When take turns to clean it accordingly. Besides, they have a I was first assigned to this place, which was a year and six monthly cleaning campaign for the entire compound as months before, I even cried. But I together with the well. households managed to overcome the challenges to see all these successful changes,‖ elaborates Sr. Mulumebet. Mimi and her neighbors are very happy now. After the Sr. Mulumebet is one of the Urban Health Extension construction of the toilet, they have noticed a lot of Professionals in Woreda 5 Health Center assigned at changes in their lives. ―Our children are healthy now. We ketene 8. There are about 500 households under her can sit in the compound and socialize and held different catchment area. Most of the time she visits her sites discussions. We are not ashamed about our compound within 2 weeks‘ time; but there are also times when she now. We have a bank account at the Commercial Bank of goes every week. Ethiopia and currently we have 1073 ETB,‖ added Mimi.

The new communal latrine, with eight rooms, is

constructed right next to the previous one which only has one room.

―For such kind of a job, courage is very essential. We have Now the only thing that the households mention as a worked very hard to make the change that we are seeing challenge is the sewerage line that is crossing through now. For that, I personally would like to thank my their compound. supervisor Sr. Letebrehan and also JSI‘s implemented ―About the sewerage line, I have reported the case to the project Strengthening Ethiopian Urban Health Program Woreda Health Bureau and I hope to get a solution for (SEUHP) for their continuous support and that very shortly,‖ explained Sr. Letebrehan. encouragement. If it wasn‘t for the different trainings that These changes happened after a lot of efforts made by the they provided for us and for the material supports, it Urban Health Extension Professionals. wouldn‘t be viable to work towards these changes,‖ concluded Sr. Mulumebet.

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Annex 2: Summary of Emergency WASH Construction Activities: Progress in FY17

Project Kebele/ SN Region Town Activity status Description Village

Head work finished and left with pump 1 Hand-dug well Amhara Sekota Telela installation and cattle trough works 2 Hand-dug well Amhara Sekota Gudguda Canceled Head work finished and left with pump 3 Hand-dug well Amhara Sekota Tach Tsibaya installation and cattle trough works Head work finished and left with pump 4 Hand-dug well Amhara Sekota Wikir Filfil installation and cattle trough works Latrine 5 Amhara Sekota Ketena 10 Under tanker stand works renovation New public 6 Amhara Sekota Mekenziba Under slab works latrine 7 Water Under walling work Amhara Sekota Sekota storage Pipeline Tigray Alamata Harkista Under fencing works 8 extension WSP and 9 Tigray Alamata HC/OTP Under tanker maintenance latrine New public Enda Yesus 10 Tigray Alamata Under roofing works latrine site Church Rehabilitation Tigray Adigrat Bikot 11 Completed HDW Pipeline Tigray Adigrat Mitsawerki 12 Completed extension Water Adigrat 13 Tigray Adigrat Completed storage HC/OTP New public 14 Tigray Adigrat Mitsawerki Completed except septic tank works latrine Water supply Completed except automatic controller 15 Amhara Kombolcha HC/OTP system installation 05 Abinet Completed except some correction 16 Bathing room Amhara Kombolcha school works Latrine 17 Amhara Kombolcha 03 Kebele Completed renovation New public 18 Amhara Kombolcha 04 Kebele Under ceramic works latrine Spring Amhara Kombolcha 07 19 maintenance Community Completed Latrine Amhara Kemissie Samte 20 Completed renovation Water supply Amhara Kemissie HC/OTP 21 Completed system Pipeline 22 Amhara Kemissie Rappi Completed except checking the system extension New public 23 Amhara Kemissie Market Under ceramic works latrine

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