STRENGTHENING ’S

URBAN HEALTH PROGRAM

FY18 ANNUAL REPORT STRENGTHENING ETHIOPIA’S URBAN HEALTH PROGRAM

ANNUAL REPORT

OCTOBER 2017 – SEPTEMBER 2018

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 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 MARPs most at risk populations M&E monitoring and evaluation

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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

I. PUBLICATIONS/REPORTS ...... 6 II. TECHNICAL ASSISTANCE ...... 6 III. TRAVEL AND VISITS ...... 7 IV. ACTIVITY ...... Error! Bookmark not defined. SUMMARY MAJOR ACCOMPLISHMENTS IN THE REPORTING PERIOD ...... 9 IR 1: IMPROVED QUALITY OF COMMUNITY‐LEVEL URBAN HEALTH SERVICES ...... 10 IR 2: INCREASED DEMAND FOR FACILITY-LEVEL URBAN HEALTH SERVICES ...... 33 IR-3: STRENGTHEN REGIONAL PLATFORMS FOR IMPROVED IMPLEMENTATION OF THE NATIONAL URBAN HEALTH STRATEGY ...... 43 IR-4: IMPROVE SECTORALCONVERGENCE FOR URBAN SANITATION AND WASTE MANAGEMENT ...... 62 5. OTHER KEY ACTIVITIES ...... 75 6. DATA QUALITY ISSUES DURING THE REPORTING PERIOD ...... 78 7. COMMUNICATION AND DOCUMENTATION RELATED KEY ACTIVITIES AND ACCOMPLISHMENTS ...... 79 8. OPERATIONS AND FINANCE: KEY ACTIVITIES AND ACCOMPLISHMENTS ...... 82 9. CHALLENGES AND PLANS TO OVERCOME THEM DURING THE REPORTING PERIOD ..... 86 10. MAJOR ACTIVITIES PLANNED IN THE NEXT REPORTING PERIOD ...... 86 Annex II: SEUHP Strategic Information Action Plan 2018 ...... 91 Annex III: Summary of Measurable WASH LMG Result Achievements in selected towns of Amhara region between June and September 2018 ...... 94 Annex IV: Best practice ...... 96

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SUMMARY MAJOR ACCOMPLISHMENTS IN THE REPORTING PERIOD

The followings are major achievements of the first six months of FY18 (October 2017-March 2018):

. National level Master TOT and regional level TOT of second round IRT conducted for 23 and 261 participants respectively from SEUHP supported regions covering the modules on major communicable diseases, major NCDs, and Basic First Aid. The IRT was rolled out for 2,263 UHE-ps in SEUHP supported towns. . 1,011,835 (101.3% of the annual target) urban residents received primary care services from UHE-ps that have been receiving mentoring, coaching, and supportive supervisions from SEUHP team. . 28,856 (90.9% of target) individuals received follow up visits from UHE-ps on TB, ART, and ANC. . Intensive quality improvement efforts were undertaken in 21 model QII demonstration health centers that are identified as learning and demonstration sites. Sites received follow up visits whereby technical supports were provided on reviewing their plans, monitoring their performances, and documenting lessons learned among others. . Support provided for primary health care reform sites in SEUHP supported regions. So far, the family health teams in Addis Ababa, , Tigray and regions have provided door-to-door and school- based services for 36,416 individuals. . A 26 episode serial radio drama that focused on RMNCH, HIV, TB, and urban WASH produced and aired using the Ethiopian National Radio Station through a nationwide coverage. . A four episode documentary film that focuses on urban HEP and urban WASH was produced in collaboration with EBS TV and aired. . 28,856 individuals who defaulted from clinical services traced and referred back to health facilities for continuity of services. . UHE-ps initiated referral for 66,546 (110.1%) individuals for further care and service at health facilities. . 1,109 government health officials and staffs in four towns attended two days of strengthening town level implementation workshops aimed at ensuring institutionalization and ownership of urban health system strengthening initiatives. . 2,873 UHE-ps received targeted supportive supervision from CTHOs and HCs from SEUHP supported towns. . Piloting of UCHIS accomplished and documented in three towns (Addis Ababa, Bishoftu, and ). . 28,298 (112.9%) people assisted for gaining access to improved sanitation facility (latrine). . 52,814 (125.1%) households assisted to have proper liquid waste/grey water management facility. . 43,937 (132.5%) households assisted/supported with gaining access to proper Solid Waste Management . Different WASH facilities including public latrines, communal latrines, hand dug wells, pipeline extensions etc. constructed/renovated at four SEUHP supported towns were inaugurated in the presence of national, regional, zonal, and town level higher officials including State Minister for FMOH, RHBs and Mayors and cabinet members. . All the remaining WASH facilities that includes constructions of one new public latrine with shower, two new public water points, renovation of one health center water supply and maintenance of one hand dug well remaining at town are completed.. Others were accomplished in previous FYs. . Project closeout is started with the 1st major staff downsizing that started as of end of June 2018.

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IR 1 IMPROVED QUALITY OF COMMUNITY‐LEVEL URBAN HEALTH SERVICES

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Sub IR1.1: Improved Knowledge, Skills, and Motivation of UHE-PS

1.1.1 Organize Integrated Refresher training (IRT) for UHE-ps

SEUHP supported FMOH’s effort to standardize Integrated Refresher training (IRT) for UHE-ps.

The FMOH started implementing the Urban Integrated Refresher Training (UIRT) initiative in 2017. Standardized competency-based modules have been developed, tested, and made available for in-service IRT. The modules included all packages of the UHEP in six major areas: Social Behavioral Change Communication (SBCC); Maternal, newborn, and child health (MNCH); Water, Sanitation and hygiene (WASH); major communicable diseases; Non- communicable diseases (NCD), and basic first aid. A key strategy for implementing Integrated Refresher Training (IRT) at scale is to have a pool of national and regional senior trainers who will organize training of trainers (TOT) for regional and local (city/ town) health staff. Trained regional staffs are required to roll-out the UIRT to all UHE-ps in their regions. Implementing these training initiatives has been a crucial achievement for the FMOH and RHBs because the UIRT allowed them to standardize and institutionalize the UHEP’s in-service training program as well as to motivate the UHE-ps.

SEUHP has played a vital role in providing technical and financial support to the FMOH and RHBs in developing, testing, finalizing, printing, and distributing the IRT modules. SEUHP also provided technical and financial support to organize a series of trainings at the national, regional and local levels.

In the first half of FY18, SEUHP conducted the second round of Master TOT for 23 national level master-trainers and 261 regional trainers. Through these trainers, urban IRT has been cascaded to all towns including those not supported by SEUHP. The majority (85.5%) of the UHE-ps, in Oromia, Amhara, SNNP, Addis Ababa, and regions received the IRT in the first quarter (Table 1). During the second quarter, an additional 329 UHE- ps were trained from Harari and Tigray regions. A total of 2,263 UHE-ps received UIRT during the first half of FY18. SEUHP fully financed the master training of trainers while the regional training of trainers and cascading trainings were financed by the FMOH. SEUHP technically supported regional training of trainers and cascading trainings by preparing training plans, printing and distributing training materials, and providing facilitators.

In consultation with the FMOH, SEUHP developed a training quality assessment tool that can be used for supervision by SEUHP staff as well by government health experts at FMOH and regional levels. The SEUHP regional teams (Dire Dawa, Oromia, and Amhara) used this tool to monitor the quality of the roll-out training.

The urban IRT is highly needs-based, standardized, and government-owned. It is anticipated that as a result of this training, UHE-ps will improve their performance in providing quality UHEP services to the community.

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Table 1: Summary of second round IRT participants at national, regional and town level,

October-March, 2018

Region Master TOT Regional Roll out TOT (UHE-ps) Tigray 4 261* Afar 2 Amhara 6 74 319 Oromia 7 112 404 SNNPR 6 58 250 Benshangul Gumz 4 Gambella 4 Somali 3 Harari 1 68* Dire Dawa 2 17 121 Addis Ababa 6 840 FMOH 1 National 46 261 2263 *Organized during the second quarter of this reporting period

1.1.2 Post-IRT skill reinforcement visits in SEUHP target towns

The FMOH will evaluate the efficiency and effectiveness of the urban IRT, as well as its impact and outcomes. This evidence will help program managers and supervisors take timely measures including (a) organizing skill reinforcement coaching for UHE-ps, (b) adapting the training approach, (c) revising training modules, and (d) finding a way to ensure more competent trainers.

SEUHP in consultation with the FMOH developed a standard manual (A Manual for Conducting Post-training Evaluation) to support regional government staff in conducting post urban IRT evaluations and making timely corrective actions. Based on this, a half-day orientation was facilitated by SEUHP, together with FMOH experts, for 26 UHEP coordinators in Amhara, Tigray, Oromiya, SNNP, Dire Dawa, and Harari. The orientation focused on how to perform the evaluation, using the manual. SEUHP in collaboration with FMOH developed a sample data collection tool and included it as an annex in the manual.

In this reporting period, post-training follow-up visits were conducted by a group of supervisors from THOs, HCs, and SEUHP staff, in , , , , and Bishoftu towns of Oromia region with the aim of assessing the training outcomes of the first three IRT modules (SBCC, MNCH, and WASH). The findings of the visits revealed that almost all UHE-ps in Nekemte, Batu, and Adama towns were very happy to receive standardized training which improved their skills, and UHE-ps reported that they felt empowered to communicate effectively with their clients. Overall, UHE-ps acknowledged the importance of the IRT in improving their attitudes, skills, and knowledge to provide services to their community.

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1.1.3 Support FMOH and RHB in implementing UHEP optimization process

Research showed that the Health Extension Program (HEP) was not being implemented as expected, and in FY17 the GOE acknowledged that the program needed to be optimized. To do so, the FMOH began a series of interlinked activities in June 2017 and established a national health extension program (HEP) optimization task force, of which SEUHP is a member. The optimization process includes the rural, urban and pastoralist HEP. The taskforce conducted a rapid assessment of the implementation status and functionality of the HEP in rural, urban, and pastoralist areas and wrote a report with recommendations to further strengthen the HEP program in all regions.

SEUHP has been technically and financially supporting the entire process of the urban health extension program optimization since the second quarter of FY17 and assigned its senior staff to work with the core team and Technical Working Group (TWG) at the FMOH level. The optimization document lists a number of recommendations to tackle HEP implementation bottlenecks and make the program more successful.

SEUHP continued providing strong technical support to the FMOH to make the HEP optimization initiatives a top agenda for stakeholders and development partners through a series of national advocacy sessions. SEUHP has been working as a member of the Urban TWG responsible for the overall processes of organizing these advocacy sessions. These advocacy sessions held in different parts of the country included conferences, seminars, workshops, panel discussions, symposiums, exhibitions, and broadcasts.

During the third quarter of FY18, the SEUHP team worked in close collaboration with the FMOH to organize the HEP optimization workshop integrated with the second national urban health conference from May 15-17, 2018 in Addis Ababa. SEUHP made the following contributions in the organization of the workshops.

. Developed operational plans and mobilized . Organized exhibition corners and displayed resources. SEUHP’s products. . Set agendas for the workshop and conference. . Organized and led panel discussions. . Identified relevant researchers and presenters . Documented the conference proceeding. and invited them for presentation. . Prepared key note speeches. . Printed documents, brochures, flyers, and banners. . Reviewed presentations and other documents. . Supported the audio-visual documentary on HEP. . Enriched HEP optimization documents. . Financially supported participants who came from SEUHP operational towns. . Made presentations on selected topics.

In order to translate the HEP optimization recommendations to actions on the ground, the FMOH capitalized on the preparation of the road map. During the fourth quarter of FY18, SEUHP has been widely represented in national taskforce meetings and provided technical support on a series of activities including drafting the road map. SEUHP also provided financial and technical support to FMOH to further strengthen the implementation of Woreda Transformation. A woreda transformation monitoring guide and tools have been revised and SEUHP Central Office staff participated in a field visit to monitor implementation of Woreda Transformation in Harari and Dire Dawa. As part of cascading the HEP optimization process at regional level, SEUHP provided need-based support to successfully organize regional level workshops in all regions.

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Box 1: Urban HEP Optimization: Recommendation and Directions

Management and administration related recommendations  Create a structure that supports the urban health extension program from FMOH to Health Center level.

 Place UHE-ps at a health center or in sub-stations at kebeles and ketenas.

 Provide coaching and mentoring training for HC staff to structure support provided for UHE-ps.

 Implement community-based quality improvement initiatives in all health centers.

 Improve multi-sectoral integration between all stakeholders including government and private sectors

Human resource management related recommendations  Provide level 4 health extension training widely.

 Evaluate UHE-ps based on elements from level 4 health extension training or clinical nurse.

 Create opportunities for health extension professionals to continue their education based on their interests.

 Include UHE-ps in different government incentives in accordance with their education and experience.

 Allow UHE-ps to transfer from one place to another based on the rules and regulations of the public service.

 Provide the health extension professional with uniforms.

 Identify UHE-ps professional gaps and provide them with sequential on the job refresher trainings.

Service provision related recommendations

 Revise the health extension packages when required.

 Assign additional UHE-ps, per the number of the kebeles, to address the hygiene and sanitation challenges seen in different towns and cities.

 Ensure access to health services for hard-to-reach populations through household level service provision.

 Implement and expand the Primary Health Care Reform to major towns by providing required human resource and materials based on the manual.

Medicine and medical equipment related recommendations

 Identify medicine and medical equipment needs and create a supply system to avail it.

Community Engagement related recommendations

 Enhance model family training and prepare a manual to create model families who can sustain the participation and ownership of the community.

 Implement electronic community health information system in all towns/cities.

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Sub IR 1.2: Improved UHE-ps Access to Standard Health Service Delivery Toolkits and Service Standard Manuals

1.2.1 Maximize the utilization of UHEP implementation manual and reference toolkits

Previously, one of the UHEP’s major challenges was the lack of standardized program implementation manuals and service delivery tool kits. However, in FY16, SEUHP, in collaboration with the FMOH and RHBs, developed, validated, printed, and distributed the standardized/revised urban health extension program (UHEP) implementation manual. Additionally, a series of regional and town level orientation workshops were organized for all stakeholders on the revised implementation manual. Based on the revised UHEP implementation manual, SEUHP also identified, customized, and printed selected relevant UHEP-services related job aids and put them together in a folder as a package of UHEP implementation tool kits.

. In this reporting period, as part of SEUHP’s effort to improve the quality of health services provided by UHE-ps, the regional SEUHP teams in SNNPR, Amhara, Oromia, Addis Ababa, and Dire Dawa have been reorienting, monitoring, and conducting supportive supervision and performance review meetings and have organized town level workshops to ensure the UHEP implementation manual is used. The Tigray regional SEUHP team distributed a variety of guidelines, standard operating procedures (SOPs), protocols, flipcharts/algorithms etc. to all UHE-ps in SEUHP-supported towns to help them provide standardized services to their communities. In order to ensure use of these job aids and tools, the regional team also conducted a series of follow-up visits to Mekele, Adigrat, Aksum, Shire, Alamata, and Maichew towns. . Health Centers in all regions have started incorporating the activities of UHE-ps into their annual work plans and are implementing in line with the standards of the UHEP Implementation Manual. . UHE-ps in all of the SEUHP targeted towns have started prioritizing households and providing house-to- house services based on the revised implementation manual with special emphasis given to under-5 children and pregnant mothers. . The staffs of several health centers are providing technical support to UHE-ps (ratio of one supervisor to two UHE-ps). . In many of the towns health centers have officially assigned UHEP-focal persons. . Town health offices in Ambo and Gimbi began to include relevant stakeholders, who would benefit in strengthening UHE-ps, in their quarterly program review meeting. . Health centers are consistently providing or refilling supplies including pregnancy test kits, glucometers, family planning methods, condoms, blood pressure apparatus, stethoscopes, thermometers, vitamin-A, deworming tablets, mid-upper arm circumference, weight and height scales to UHE-ps. . Weekly health center level meetings are taking place and led by health center directors.

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Sub IR 1.3: Advanced Implementation of Quality Improvement Initiatives (QII)

1.3.1 Advance the implementation of QII in selected sites

SEUHP’s supported QI team at Butajira Health Center has greatly improved services quality including laboratory services for Antenatal services.

SEUHP has been implementing the quality improvement intervention for community-based health services; initiatives which are showing promising results. SEUHP focused on 21 selected quality improvement sites and provided close follow-up and support to create learning sites. SEUHP has been providing technical support for the quality improvement teams to ensure their functionality and also conducted a series of advocacy meetings to ensure government ownership and sustainability of quality improvement initiatives at the regional and sub-city levels.

Some of the region-specific support in FY18 included:

Addis Ababa: In this reporting period, to support the sustainability of the quality improvement initiative, a toolkit has been developed and distributed to all quality improvement implementing health centers. The purpose of the toolkit is to equip quality improvement sites with all necessary quality improvement tools and guides and to use these guides as references for their day to day activity. The kit contains SEUHP quality improvement tools, the national strategic and implementation manual, a quality improvement problem analysis guide, a quality improvement objective tracking sheet, a quality improvement planning template and a quality improvement training guide. It also includes quality improvement monitoring and evaluation tools: a scorecard, follow-up checklist, planning template and a progress tracking sheet.

Quality Improvement follow-up visits were conducted for eight quality improvement teams: Woreda 5, Woreda 12 and Woreda-11 health centers in Nifas Silk Lafto sub-city; Ras Emiri, Kebena, and Woreda 7 in Arada sub City; Woreda 03 and Woreda 5 health centers in Kolfe Keranio sub city; and Woreda 12 and Woreda 13 health centers in Yeka sub City. During these visits, 55 quality improvement members (35 females) received the quality improvement follow-up support and technical guidance. During the supportive supervision, the functionality status of the quality improvement team was assessed using the scorecard.

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These health centers showed impressive progress for the selected quality improvement indicators tracked. For example, the coverage of completed referral at Woreda 05, Woreda 11, and Woreda 12 health centers of Nifas Silk Lafto sub-city increased from 50%, 64%, and 29% in the fourth quarter of FY17 to 88%, 77%, and 56% in the third quarter of FY18 respectively. Quality improvement teams regularly monitor UHE-ps’ individual performance during their monthly quality improvement meetings. Nifasilk Lafto Woreda 05 health center achieved remarkable progress during FY 2018; complete referral increased from 270 to 518, HIV testing use from 36 to 170, non- communicable diseases screening from 50 to 135, and defaulters traced from 6 to 16. Kolfe Keranyo Woreda 03 health center the postnatal care coverage has improved from 71% in quality improvement to 87% in Q4 of the FY18. While antenatal care-1 to antenatal care-4 dropout rates decreased from 31% to 23.3%.

Amhara: In the reporting period, a quality improvement review meeting was conducted in for all six health centers and in Debre Markos for three health centers to review the performance of the quality improvement teams, share experiences among the health centers, identify challenges, and develop regular quality improvement plans to sustainably improve the health system. The team conducted checklist-based support to UHE-ps, identified gaps, and addressed them during the field visit. Observations during follow-up visits showed that the quality improvement initiative is functioning well at Hidassie health center in Bahir Dar town in terms of providing regular monthly support, holding monthly meetings, and providing timely feedback and follow up. The support focused on data quality, documentation, and reporting and direct service provision. In , Debre Birhan, Gonder, and Debre Markos the quality improvement team is actively involved in problem solving and integrating with health centers’ performance monitoring team.

The SEUHP regional team provided technical support to quality improvement teams in Debre Markos (Debre Markos and Hidase health centers) and Bahir Dar (Abay, Bahir Dar and Ginbot 20 health centers) towns with the aim of sustaining quality improvement intervention. The quality improvement team in Debre Markos health center identified two measurable indicators: “improving isoniazid (INH) uptake for antiretroviral treatment (ART) clients from 34.5% in June 2018 to 70%”; and “reducing ART defaulters by 50%.” The team exceeded its INH goal and provided 74% of persons living with HIV (PLHIV) on ART with INH. However, the team only traced 11 (8%) of ART defaulters in the quality improvement project period which indicates a need for greater focus on defaulter tracing.

Changes in these health centers are attributed to the improvements in the quality of counseling provided by the service providers in the ART room and through discussion with health center staff. The quality improvement team meets and reviews performance regularly and documents minutes. The measurable indicators identified by Hidassie health center quality improvement team were improving the postnatal care service within seven days to 100% of mothers, provision of child care to all children, adherence to iron for 90 days, and improving data quality for UHE-ps. The strategy designed to improve postnatal care coverage was to integrate postnatal care services with BCG immunization. This approach was found to be effective in achieving the targets. Abay health center in Bahir Dar town quality improvement team developed two quality improvement projects focusing on “improving the index case testing” and “improving data quality.” The quality improvement team intervened to track index cases from the known PLHIV and provided services; conducted data quality checks. Index case testing was done for 56% of PLHIV families as compared to 11% at baseline. Data quality has improved from 60% to 95%.

Harar: The SEUHP team, in collaboration with RHB staff and government health experts, conducted six rounds of supportive supervision visits to strengthen quality improvement. The quality improvement team in Jinella HC was supported to update the follow-up and progress chart for the selected quality improvement indicators. Much of the support and coaching is now being performed by the RHB experts, a significant sign of quality improvement initiative institutionalization in the region.

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Oromia: The SEUHP regional team, in collaboration with town health offices, organized an integrated QI review meeting and refresher training workshops in six health centers—Nekemte, , Asela, Adama, and Bishoftu towns—to review the performance of the quality improvement team and to sustain its achievements. A total of 87 individuals (32 females) including UHE-ps, health center staff, and town health offices representatives participated in the workshops. The quality improvement teams presented their nine-month performance, including what didn’t go well, limitations, and challenges. The refresher training targeted newly hired staff members. The topics covered included basics of quality improvement, measuring quality, identifying and analyzing root causes to the problem, and formulating quality improvement interventions. The participants developed a three-month quality improvement action plan. The prioritized areas for quality improvement included referral feedback documentation, fourth antenatal care visit coverage, early postnatal care, presumptive tuberculosis case referral, and defaulter tracing. The SEUHP team will support and monitor the progress in the subsequent months.

The Adama health center team developed an action plan to help them revitalize the quality improvement efforts and focus on improving referral, postnatal services by UHE-ps, defaulter tracing, and strengthening school based UHEP implementation. The Bishoftu health center team will focus on overall UHEP implementation improvement. During this reporting period Ambo, Jimma Mendera Kochi health center and Nekemte health center quality improvement teams received technical support from the SEUHP regional team while preparing their annual plan.

SNNPR: Quality improvement sites received follow-up visits and were provided with technical support to review their plans, monitor their performance, and document lessons. In this reporting period, quality improvement initiatives, including quality improvement team functionality assessments, quality improvement team performance review meetings, and technical support with on job refresher training were carried out in five health centers to strengthen their quality improvement activities. Follow-up activities were conducted in Wolkite, Butajira, , Arbaminch, and Hossana towns. Quality improvement review meetings were attended by 74 participants from the five health center including Directors of PHCU, health center administrative heads, Disease Prevention and Health Extension Program coordinators town health offices, and UHEP focal persons from their respective catchment HCs. During quality improvement team review meetings, the performance progress, areas of strength and challenges were discussed. The key challenges included an inability to measure progress. This was attributable to an absence of proper tracking of indicators, a lack of proper documentation, and unclear improvement objectives. Thus, action plan was prepared to improve performance gaps and enhance existing strengths.

Findings functionality status assessment conducted by the five quality improvement teams revealed that currently three of them are progressing well. The assessment was done on six areas of quality improvement team functionality including quality improvement structure, level of activity, quality improvement measurements done, quality improvement interventions done, follow-up measurements, and quality improvement team activities documentation. Well-performing quality improvement teams were found in Butajira (88%), Sodo (82%) and Hossana health center (75%). Arbaminch (65%) health center has a medium level of quality improvement performance and Wolkite (35%) HC performs below the expected level. The quality improvement teams have better performance in relation to quality improvement structure and quality improvement intervention with average score of 9.8 and 8 out of 10 scoring points. Low performance was observed on documentation next to the follow-up measurements. Likewise, the quality improvement teams at Butajirra, Sodo, Hossana and Arbaminch health centers are performing very well with all the team members currently available and functional, the health center heads and quality improvement focal persons are committed to lead the team, meetings are done monthly with minutes being documented, and quality measurements are being performed consistently. To

SEUHP FY 18 Annual Report 18 revitalize and enhance the poor performance of the Wolkite health center quality improvement team, a half-day orientation workshop was conducted to refresh the quality improvement team members and health center management.

Tigray: Monitoring and follow-up visits were held in quality improvement implementation sites (health centers) on a monthly basis. In all quality improvement sites ( , Adigrat, Shire, Maichew, Aksum, and Alamata) the provision of regular support to further strengthen quality improvement implementation, tracking of monthly quality improvement progress, and documentation of quality improvement activities has improved. As a result of close follow up and support provided by SEUHP, some of the achievements observed in the quality improvement implementation health centers include referral focal persons assigned, city or town health offices and health centers are monitoring quality improvement sites regularly, decreased measles vaccine defaulter rates; improvements in early defaulter notification and tracing, registering clients’ full address during vaccination start up, better UHE-ps to health centers staff linkage, increased partner testing for HIV, increased referral and completed referral, increase in antenatal care service referral, improved care for HIV positives, necessary supplies refilled, and improved documentation of best practices (Table 2). Despite these achievements, there have been challenges including: a shortage of HIV test-kits, frequent turnover of key quality improvement team members, and irregular meetings.

Table 2: Summary of changes documented following implementation of QII in selected sites/health centers; October 2017-March 2018

Region/town Quality improvement Indicators Baseline Current status teams Amhara Bahir Dar Wuseta Referral feedback 36% Jan 2017 49% Feb 2018 Health Center HIV testing and counseling services 50% Jan 2017 97% Feb 2018 Shimbit Decrease measles vaccine defaulter 26% in Dec. 2017 6% in March Health Center rate 2018 Increase HIV testing yield 0.5% in Dec. 2017 1% in March 2018 Abay Health Improving the Index case testing 11% June 2018 56% Sept 2018 Center Ginbot 20 Improving data quality 60% June 2018 95% Sept 2018 Health Center Debre Debre Markos HTC services 48%, September 72% Feb 2018 Markos Health Center 2017 Improving Isoniazid (INH) uptake 34.5% June 2018 74% Sept, 2018 for ART clients Harar Jinnela Health Increased number of completed 62% in FY18 quality 74% in FY18 Q2 Center referrals improvement

1.3.2 Work with the FMOH and RHBs to institutionalize QI Initiatives (QIIs)

In the effort to support the sustainability and institutionalization of ongoing quality improvement activities, it is essential that a standardized quality improvement implementation manual for community-based health services is developed.

In this reporting period SEUHP, in collaboration with the FMOH Health Extension and Primary Health Services (HEPHS) Directorate and Health Service Quality (HSQ) Directorate, organized a three-day workshop to develop a national Quality Improvement Manual for Community-Based Health Services from June 7-9, 2018 in Adama

SEUHP FY 18 Annual Report 19 town. Nineteen experts (six female) from various FMOH directorates (Health Extension and Primary Health services, Health Service Quality, Clinical Services and Communicable Diseases), RHBs (Addis Ababa and Oromia), Health Center implementing HCs from Addis Ababa (Lafto Woreda 12 and 05 HCs and Kolfe Keranyo Woreda 05 HC) and partner organizations attended. Partners that participated are Nutrition International, Save the Children, Growth through Nutrition, Institute for Healthcare Improvement, Universal immunization through improving family health services, and Last 10 Kilometers (L10K).

In Addis Ababa, quality improvement has been seen sustained in the government system. In all health centers, Health Center teams have prepared updated plans for EFY 2011. Some health centers have allocated budgets to provide refresher training for new quality improvement team members. The FMOH Quality of Health Care Directorate is planning to use the SEUHP quality improvement sites to pilot new quality improvement projects and the list of health facilities has been shared with the Directorate. In Tigray and Harar, RHB experts and heads of health centers are conducting supportive supervisions regularly.

SEUHP’s Senior Quality Improvement Advisor participated in the first Annual Africa Forum on Quality and Safety in Health Care in Durban, South Africa February 19-21, 2018. In the workshop, the experience of SEUHP’s Quality Improvement initiative under the title 'Strengthening Referrals and Integration of Community and Facility Health Services through Quality Improvement [Initiative]' was presented and discussed. Sub-IR1.4: Improved referral and linkages between UHE-ps and facilities

1.4.1 Standardize/institutionalize referrals into Government’s system and make referrals and linkages between UHE-ps and facilitates fully functional

One of the challenges related to referrals has been lack of standardization of the referral system because of infrequent use of the national referral guidelines. To standardize the system, SEUHP introduced a referral tool for UHE-p-initiated referrals from the community to Health Centers and developed a referral toolkit and directory for all 49 towns/cities through various initiatives. SEUHP also initiated QIIs in a majority of the program towns to increase the proportion of complete referrals.

In FY18, SEUHP continued efforts to improve the referral, defaulter tracing, and follow-up systems using different platforms such as primary health care reform, quality Improvement initiative, town level workshops, supportive supervision visits, review meetings, leadership and management, integrated refresher training sessions, etc. 2,313 pads of referral slips, 30 referral and defaulters tracing registers, and 20 pregnant women and under-one registers were distributed to UHE-ps; routine supportive supervision and follow-up visits and health center monthly meetings were undertaken to ensure the proper utilization of different formats and to further strengthen the referral systems between the health centers and the UHE-ps; experience sharing visits between health centers were organized in Oromias and most health centers assigned referral focal persons and provided referral collection boxes at the service delivery units.

In this reporting period, 66,546 individuals (110.1% of the annual target) were referred to health centers for further care and support, and 17,281 completed referrals were documented, accounting for 65.7% of the annual target in the seven SEUHP-supported regions (Table 6). A total of 2445,853 of the referrals and 3283 of the completed referral cases were made in quarter IV.

Regarding the types of referrals made in the reporting period, majority of the referrals were for EPI/immunization services, antenatal care services, and family planning services accounting for 19.6%, 12.8%, and 11.2% of all referrals, respectively (Table 3).

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NB: Number of people referred is different from number of people by type of referral service as an individual might be referred for multiple cases in the reporting period. Table 3: Referrals made by type of service, October 2017-Septemeber 2018

Q4 FY18 Proportion (share Types of services referred Oct.2017- of the total for July-Sept. 2018 Sept.2018 referred in FY18) Immunization 2,487 12,411 19.6 Antenatal care 1,669 8,148 12.8 Family Planning 1,162 7,134 11.2 Tuberculosis 1,357 5,696 9.0 Nutritional support and counseling 925 5,175 8.2 HIV testing and counseling 466 4,103 6.5 PMTCT 549 2,073 3.3 Non-communicable diseases 298 2,002 3.2 Delivery 194 1,058 1.7 Postnatal care 237 1,002 1.6 Other medical diagnosis and treatment 2,760 14,631 23.1

1.4.2 Develop Supply Management System for UHEP

SEUHP drafted a handbook for the UHE-ps on Logistics Management Systems to be used as a standardized guideline and reference tool to support the creation and strengthening of a UHEP supply chain management system. The handbook was submitted to the FMOH for further comments. SEUHP in collaboration with FMOH organized a consultative workshop to finalize the UHEP’s logistics management handbook. A second round workshop was conducted during the fourth quarter of FY18 to finalize the handbook. A group of high level experts from FMOH and SEUHP worked on the handbook for three days and finalized the handbook and translated it into .

About 28 UHE-ps from Jimma town, Oromiya region were oriented on the Internal Requisition and Reporting Format (IRRF) and 10 Kebeles with oriented UHE-ps received IRRF pads. UHE-ps and health centers have started submitting their monthly request for supplies as a component of routine monthly activity reports. Following the town level workshops aimed at strengthening the town level implementation of UHEP, almost all SEUHP- supported health centers in Addis Ababa have developed action plans to make UHE-ps directly responsible for requesting and receiving the required UHEP supplies and drugs per the Implementation Manual, such as Vitamin A, Albendazole, short-acting family planning, blood pressure apparatus, gluco-meter, etc. The development of this guide is expected to address the critical problem related to accessing supplies and drugs for the urban health extension program. Sub IR 1.5 Increased Access to and Coverage of HIV Prevention, Treatment, and Care Services

To sustain community-level HIV interventions in FY18, SEUHP in coordination with town health offices and health centers, continued providing the usual support to UHE-ps. The support includes: in-service training and orientations; supportive supervision and follow-up visits; target mapping of widowed, divorced, separated and

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Index cases, facilitating out-reach HIV testing and counseling services for target population; facilitating the provision of HIV test kits to the UHE-ps for targeted testing and providing care for people living with HIV.

As a result, UHE-ps have been providing HIV testing and counseling and linking of HIV positive cases to ART and care and support services including adherence counseling, family planning, condom distribution, nutritional screening, defaulter tracing and referrals for social support.

Accordingly, in this reporting period, 9274 individuals received HIV testing and counseling service from UHE-ps, with an HIV positivity rate of 1.0%. The HIV positivity was higher among females (1.1%) than males (0.8%).

Table 4: Clients received HIV testing and counseling (HTC) services by test result, age-sex and regional distribution, Oct. 2017- Sept. 2018

Q4 (July.-Sept 2018) Annual (Oct. 2017-Sept 2018) HTC Total Male Female Total Male Female Total Tested 2,294* 633 1,659 9,277* 2,722 6,554 Total: Negative 2263 626 1635 9182 2700 6482 Age/sex: 10-14 203 119 84 625 275 352 Age/sex: 15-19 434 144 290 1,674 525 1,152 Age/sex: 20-24 603 115 488 2,588 588 1,997 Age/sex: 25-49 959 230 727 4,058 1,223 2,833 Age/sex: 50+ 64 18 46 237 89 148 Total: Positive 31 7 24 95 22 72 Age/sex: 10-14 1 1 0 1 1 0 Age/sex: 15-19 2 0 2 7 1 6 Age/sex: 20-24 10 1 9 23 1 22 Age/sex: 25-49 17 5 12 61 19 42 Age/sex: 50+ 1 0 1 3 0 2 Yield (%) 1.4 1.1 1.4 1.0 0.8 1.1

*Summation between males and females may not be less than the Total column due to missing values in the sex column either during recording at the time of service delivery or during data entry.

In the second quarter, SEUHP had a half day meeting with the new USAID-funded Project Hope’s Community HIV Care and Treatment Program to share experiences on community-level HIV prevention initiatives. Issues covered during the meeting included the development of standard in-service training materials for UHE-ps; the need for in-service or on-the-job training for UHE-ps on basic HIV prevention activities such as target mapping, targeted HIV testing and counseling, referral/ linkage to ART and psychosocial services, adherence counseling and other home-based care and support.; provision of updated job aids and tools to UHE-ps to help them provide appropriate HIV services; the need for effective and quality supportive supervision for UHE-ps and their supervisors on regular basis; and organizing regular performance review meetings at health centers and town health offices to facilitate linkage between UHE-ps and health centers. Coordination, achievements, lessons learned, and challenges concerning the above-mentioned activities were explained to the staff of Project Hope’s Community HIV Care and Treatment Program. As a member of National Task Force, SEUHP contributed to the

SEUHP FY 18 Annual Report 22 development and piloting of the Urban Health Extension Worker-managed Community ART Refill Groups in Addis Ababa. Sub-IR 1.6 Strengthen TB Case Detection and Increase Treatment Success Rate by Implementing Community TB Care Interventions

1.6.1 Strengthen TB case detection and increase treatment success rate by implementing community TB care interventions

Community-based TB care (CBTC) is an effective way to deliver TB prevention, care, and treatment services. UHE-ps play an important role in improving TB case detection and TB treatment outcomes through TB treatment follow-up and defaulters tracing at the community level. UHE-ps can also undertake contact tracing of confirmed TB cases, with an emphasis on children under five, PLHIV, and all symptomatic close contacts.

In this reporting period, SEUHP regional teams provided technical support to the respective RHBs while cascading the communicable disease IRT module to improve UHE-ps knowledge and skills in detecting and referring TB suspect cases, counseling on treatment adherence, and tracing defaulters. In Oromia region, the THOs of Nekemte and Jimma towns and health centers were provided a day-long orientation in setting targets for presumptive TB identification or screening and referral services based on regional TB prevalence estimates.

In this reporting period 19 TB defaulters were identified and linked to health facilities for continuity of services; 1483 TB cases received follow-up visits from UHE-ps; and TB suspect identification was made for 112 HIV positive cases. Sub-IR1.7: Increased Access, Coverage and Utilization of High-Impact MNCH Services among Vulnerable Urban Communities

1.7.1 Enable UHE-ps to provide MNCH services

According to the revised Urban Health Extension Program implementation manual, UHE-ps are expected to provide diverse maternal, newborn and child health (MNCH) services. In this reporting period, SEUHP continued providing technical support to UHE-ps in different aspects including identifying, registering, and following up with pregnant mothers and organizing comprehensive MNCH-focused services in their catchment areas, including nutrition screening for under-five children and preganant and lactacting woman. SEUHP facilitated the provision of the required technical and logistical support needed from health centers as well to enhance the provision of quality maternal, newborn and child health services including antenatal care, delivery, postnatal care, growth monitoring and promotion, immunization, deworming, vitamin-A supplemenation, defaulters tracing and linkages, nutrition screening, and sanitation and hygiene, among others.

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Table 5: Summary of MNCH services provided by UHE-ps, October 2017-September 2018

QIV SEUHP FY18 Total Selected MNCH Indicators Health Health Referral Referral Education Education

FP 1,162 27,776 7,195 107,753 ANC 1,669 11,010 8,087 43,776 PMTCT 194 823 1,058 3,303 Delivery 237 4,275 1,002 16,536 PNC 2,487 12,950 12,411 45,747

EPI/Immunization 549 4,407 2,073 15,650

In FY18, UHE-ps provided direct services including health education, referral and linkage, defaulter tracing, counselling, nutrition and NCD screening, growth monitoring, and TB suspect identification among others to 1,011,835 (101.3% of FY18 target) individuals in SEUHP-supported cities/towns. Table 7 presents the number of people reached by type of services. A total of 12,597 individuals received follow-up visits from UHE-ps on tuberculosis, ART, and antenatal care. A total of 28,856 individuals who defaulted from services were also traced and referred back to health facilities for continuity of services.

Table 6: Clients reached with direct MNCH service provided by UHE-ps from Oct. 2017-Sept. 2018 FY18 FY18 FY18 FY18 FY18 FY18 Q4 Q4 Annual Annual Service indicators Q4 Annual Achieve Perform Achieve Perform Target Target ment ance (%) ment ance (%) Number of individuals reached with direct 221,715 244,853 110.4 999,189 1,011,835 101.3 services from UHE-ps Total number of individuals who were referred to facility for access to services 14536 13614 93.7 60,450 66,546 110.1 in the reporting period

Number of completed referrals 6150 3283 53.4 26,300 17,281 65.7 documented in the reporting period

Number of defaulters identified/traced and linked to health facilities for 863 814 94.3 3,345 3,657 109.3 continuity of services Number of individuals who have received a follow up visit from UHE-ps on TB, 7277 7174 98.6 31,752 28,856 90.9 ART, and ANC

Integrated outreach MNCH services have been provided in Nekemte and Shashemene towns in Oromia region during a Community Health Day (CHD). UHE-ps provided a range of services including short-term family planning, registration and follow up of pregnant women, registration and follow up of under-1 children, supplementation of vitamin A and de-worming, nutritional screening for under-5 children and pregnant women. A total of 3,346 children were screened for malnutrition in both towns out of which 23 (6 per1000) of them were identified for having severe malnutrition and referred to health facilities for further diagnosis and treatment.

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Table 7 Number of people reached disaggregated by types of services, Oct. 2017-Sept. 2018

Number of individuals Type of service reached Health Education 755,024 Follow up 185,657 Nutrition screening 177,876 Surveillance 112,523 Vitamin A supplementation for children 77,210 Referral Made 66,532 De-worming 60,616 NCD screening 48,075 Growth monitoring 45,376 FP Service 29,493 TB suspect identification 17,596 Other 17,296 PNC 12,471 HTC 9,274 ITN distribution 8,608 Condom distribution 7,044 Defaulter traced 3,658 First Aid 3,491 Vitamin A for women 1,636 Total 1,639,456* * This is a duplicated count of visits and doesn’t necessarily sum up to the total number of individuals reached through direct services as indicated in Table 6. Sub IR 1.8 Strengthen Adolescent Youth Reproductive Health (AYRH) Services

Recently, the FMOH has given priority attention to school health in order to strengthen the school health extension program. Preparatory activities accomplished include development of school health training curriculum; development and testing of school health training modules; and preparation of school health implementation guidelines. SEUHP has provided support in the development of the school health extension program curricula, training materials and implementation guidelines. All training materials were field-tested and proven to be appropriate for UHE-p in-service training, which will enhance UHE-ps’ attitude, skills, and knowledge and help them provide quality school health services.

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School Health Program Packages of the Health Extension Program

Children healthcare and follow up  Oral and eye health care; health education on personal hygiene  Make follow up of children that are on medication or that need medication and linkage to health facilities Nutrition  Nutrition education (health education)  Growth and monitoring and follow up  Nutrition screening and link to health facilities Adolescent and you reproductive health  SRH education to adolescent and youth  Counselling on family planning, safe sexual practice, HIV/AIDS, sexually transmitted infections, pregnancy  Condom and other SRH supplies distribution  Refer youth to health facilities for abortion and post abortion care  Referral for STI screening and care Prevention on major communicable diseases  Health education about HIV  Health education about tuberculosis  Screening of suspected tuberculosis cases  Health education on prevention of malaria Water, hygiene and sanitation  Promotion about construction and proper use of latrine and personal hygiene  Education and demonstration on proper storage and use of drinking water and its treatment  Education and demonstration about critical time hand washing  Support families and youth to avail hand washing water and soap near to the toilet  Conduct hand washing campaign  Counseling and education about solid waste collection and disposal  Organize sanitation campaigns on in schools

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Sub IR 1.9: Support FMOH and RHBs in the Implementation of Primary Health Care Reform

Health professionals of from Woreda 06 health center of Nifas Silk provide outreach services for the most vulnerable members of the community in their catchment area.

Based on lessons from Addis Ababa, primary health care reform (PHCR) is being implemented in all SEUHP- supported regions on a pilot basis. In FY18, SEUHP provided support to a selected group of high-performing health centers with the aim of making them models. Support provided by SEUHP included supporting the RHBs to strengthen taskforces, conducting regular technical meetings, monitoring the progress of the primary health care reform implementation, and supporting documentation of the overall processes of implementation, accomplishments and challenges of primary health care reform in the model sites of selected regions.

Lessons from pilot primary health care reform implementation revealed it has been very difficult for the UHE-ps to use the baseline data collection tools meant for categorization of households in the catchment areas especially the economic variables.

In order to address these challenges, SEUHP, in collaboration with the FMOH, organized a two-day, high-level workshop in Addis Ababa. The purpose of this workshop was to review and revise the entire national PHC reform implementation guide and the data collection tools so that the implementers would be able to fully utilize the guidelines and the tools in the process of planning, implementing, and monitoring the reform.

A group of experts with relevant knowledge and skills on primary health care were selected from the FMOH, Addis Ababa City Administration Health Bureau (AACAHB), primary health care reform sites in Addis Ababa, and SEUHP to revise the guidelines and the tools. Major revisions were made to the strategy section of the guideline, the structure and composition of Family Health Team while considering local contexts, the implementation processes (approaches) of the reform, the roles and responsibilities section, language editing , and the base-line data collection tool (to make it simple and user-friendly for the UHE-ps). The revised version of the guideline and the tools were printed and used to conduct the second round of national training of trainers on primary health care reform that took place in Harar.

A revision of the primary health care reform monitoring indicators was finalized and printed in the form of a performance monitoring tool. It will help to standardize the process of monitoring and evaluation and reporting. A total of 851 performance monitoring pads were distributed to 78 health centers that are expected to be used for one year.

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During the reporting period, FMOH and SEUHP jointly organized a three-day refresher training of trainers on primary health care reform for 26 participants selected from six regions (Amhara, Tigray, Oromiya, SNNP, Dire Dawa, and Harari). The aim of this training was to refresh and improve participants’ skills and knowledge and to enable them to train other stakeholders in the health system on how to plan, implement, monitor, and evaluate PHC reform in their cities/towns. The training was fully participatory and involved both theoretical and practical approaches. The training sessions were managed by senior facilitators assigned by the FMOH using a standardized facilitator’s guide. In addition to the classroom-based training, a half-day field visit was arranged at the PHC reform site (Jinnella HC and the respective kebeles). The visit helped participants obtain valuable experience from the pilot implementation sites. They were provided with the new planning template to use for their regional level planning.

SEUHP supported these activities by assigning a technical assistants for FMOH, a primary health care reform specialist at AACAHB and SEUHP senior staff for the revision of primary health care reform documents and the provision of the training of trainers to regional participants; developing primary health care reform training facilitation guide and primary health care reform planning template; printing and distributing the primary health care reform documents; and covering the full cost of revising the documents and partial costs of the training of trainers on primary health care reform.

Summary of activities accomplished in the regions is reported as follows:

Addis Ababa: The regional team in collaboration with the regional and sub-city experts undertook supportive supervision visits and provided technical support in the 23 primary health care reform sites and some of the health center were visited more than twice based on the intensity of support they needed (e.g., Entoto No.2 health center, Nifas Silk Lafto Woreda-06 health center, Janmeda, and Semen health centers). The process enabled the team to identify key achievements, strengths, and gaps. After the supportive supervision, written feedback was provided to each health center with an official letter from RHB.

PHC reform implementation review meetings were also conducted in each quarter. The review meetings in the second quarter were fully financed by RHB with the technical support from SEUHP, a step towards ensuring ownership of the initiative. During the review meetings, discussions were held on progress and implementation challenges and on future directions. To increase the credibility of the family health team (FHT) in the community through professional dressing codes, SEUHP provided 157 uniforms for FHT members of three health centers at Nifas Silk Lafto sub City. In addition to health center level review meetings, a city level annual review meeting was organized by Addis Ababa City Administration Health Bureau at Bishoftu. This created an opportunity to share lessons among each primary health care reform site. A total of 43 (17 female) people attended the workshop.

SEUHP organized a consultative workshop for monitoring tool revision from May 22-23, 2018 in Adama based on the recommendation from the reform sites. Thirteen experts (four female) from selected HCs and RHBs attended the tools revision workshop. A total of 851 family health team Weekly Monitoring pads were distributed to the primary health care reform sites during the fourth quarter of FY18.

In FY18, a total of 42,578 individuals received health services by FHTs from the PHC reform sites in Amhara, SNNPR, Oromia, Tigray, and Addis Ababa. A total of 14,379 individuals (39.5% of those reached in FY18) got services in the fourth quarter. Services provided include antenatal care, postnatal care, immunization, family planning services, and nutritional screening, NCD screening, chronic care and pain management, follow-up of adherence to health care or medication, counseling services, and environmental sanitation and hygiene. During the same period, 42 schools were visited and 408 students received health care services by FHTs from four HCs. Additionally, 79 individuals from seven workplaces received health services by FHT of two health centers.

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Members of the Addis Ababa City Council visited the primary health care reform intervention sites at Janmeda, Entotot # 2, and Nifasilk Lafto woreda 06 health center s. Members of the council were briefed on the FHT approach, observed activities at the community level, and had discussion about the FHT approach with Women Development Armies and end users of FHT services. The visitors appreciated the interventions in reaching the neediest segment of the population through health services and recognize the RHB and SEUHP’s efforts in initiating the intervention. Staff from Nifas Silk Lafto Woreda 06 health center shared their experiences during the second National Urban Health Conference held in 2018.

Amhara: In the first quarter, PHC reform was piloted at Tana health center in Bahir Dar. Due to staff shortages, the FHT approach was not fully implemented. In the second quarter, in response to the challenge, the RHB in coordination with the City Health Department facilitated the transfer of staff from other health facilities to meet staffing needs, and four FHTs composed of health officers, nurses and UHE-ps were established. The FHTs developed an action plan and started the HH-level services based on a categorization and prioritization of HHs. The health center is receiving close follow up from the deputy head of the RHB. The performance is reviewed every two weeks in the presence of RHB officers from HEP and primary health care reform units, ZHD heads, the health center head and FHT coordinator, and SEUHP. Assignments (action points) are given to all parties on areas of improvement to be accomplished before the next review meeting. As a result, the program has shown improvements in performance, and the approach is earning more community acceptance as compared to when UHE-ps provided services alone. FHTs are equipped with BP apparatus, weighing scales, glucometer, Diabetes Mellitus kits, pregnancy testing kits, and other necessary supplies for service provision. People who could not travel to health facilities for services are now reached by the FHT. Referrals and linkages as well as feedback systems for the community sub-teams have improved.

So far, the FHTs reached 1,371 individuals through house-to house visits and referred them to the health center for further investigation and management. The services provided include antenatal care, tuberculosis detection, hypertension management, and cancer screening. Progress review meetings were organized every fortnight led by the Deputy RHB Head and in the presence of heads and deputy heads of the city health department, health center head, health center UHEP focal person, RHB officers, and SEUHP staff. The leadership’s engaged commitment played a vital role in launching and enhancing the intervention of the PHC reform.

The RHB officially launched the implementation of urban primary health care reform during the fourth quarter of FY18. It is going to be scaled up in a phased manner to cover all urban areas in the region. Recently, the RHB launched expansion of the reform to and Dessie towns with a plan to reach all other zonal towns by the year 2020.

Dire Dawa: In the first quarter, PHCR was launched at Addis Ketema health center. In the second quarter, PHCR team, RHB and health center taskforce members participated in an experience sharing visit at Jinnela health center and selected HHs in Harar town. A consultative workshop was also held to review the implementation status in the presence of 24 (5F, 19M) participants from Dire Dawa RHB and Addis Ketema health center. During the workshop, the impact of FHT approach role in strengthening the functional linkage between UHE_ps and the health center, the acceptance of the community based health services by users, referral linkage, and defaulter tracing were given more emphasis. Starting from the third quarter of FY18, the SEUHP regional team supported the RHB’s effort in scaling up the primary health care reform (PHCU) to all eight health centers in Dire Dawa through facilitating training and introducing the primary health care reform program to the RHB management staff and responsible stakeholders. The team also actively supported the revision of PHCR implementation guidelines. SEUHP provided technical support in the form of cascading PHC reform training for staff who did not take the reform training in previous training period.

SEUHP FY 18 Annual Report 29

Harar: The SEUHP regional team along with the RHB has been supporting the PHCR implementation in Jinnela health center. As the result of the joint effort, Jinnela primary health care reform has become the learning center for the family health team approach for many regions and the other health centers within Harari region. In the first quarter, a regional-level experience sharing visit was facilitated for two primary health care reform s and one of the health centers has implemented the family health team approach. In this reporting quarter the primary health care hosted two experience sharing events for teams from Dire Dawa city administration RHB and for a team of PHC reform national training of trainer participants from Amhara, Tigray, SNNP, Oromia, Dire Dawa, and Harari Region. In the reporting quarter, Harari RHB has provided a mini laptop computer to automate the primary health care reform, and the family health team has started using it. On-the-job orientation was provided for the family health team by the RHB and SEUHP regional team on how to use the computer for updating the database, registering the new households, and viewing household information and client categorization in their respective kebeles. Family health team job aids, family health card, and reference tools are also uploaded for the family health team so that they can teach from their laptop during community activities.

SEUHP provided support to RHB efforts to scale up the PHC reform in all health center s in Harari region. In this reporting period, training on the FHT approach was provided for all health center staff with experience sharing at Jinnela health center. A two-day Family Health approach refresher training on PHCU reform was organized with the support SEUHP for the family health team members of the Jinnela family health team for 30 participants (21 Female) that include UHE-ps, UHE-ps supervisors, family health team members, and RHB. SEUHP advocated with the RHB to institutionalize the PHC reform initiatives and now the RHB has started to own urban PHCU reform.

As part of the scale up of the PHCR, Aboker and Amirnur health centers have also started the implementation of the Urban PHCU reform of the family health team approach in their respective woredas. The RHB started to own and institutionalize the family health team approach by printing report templates and daily registration and referral slips for urban PHCU reform sites in the region. In addition, to address the human resource shortage in Jinella HC, the recruitment of additional staff has been initiated and the problem is now solved by the RHB.

Oromia: The FHT in Jimma town has started providing needed services to the community as identified by UHE- ps. In this reporting period, the family health teams at Jimma town visited and provided health services for 272 HHs (316 individuals). Additionally, to strengthen the implementation of urban primary health care reform, a team comprised of Oromia RHB, SEUHP, and Jimma town health offices conducted a community-level visit to Jimma health center catchment population on April 17, 2018. The visiting team observed that the FHTs have started providing services to needy populations with non-communicable diseases screening and follow up, referrals and linkages for psychiatric patients, referrals for tuberculosis suspects with positive results at the health center, and palliative care to terminally ill patients, as well as other basic health services.

After the follow up visit, a one-day review meeting was organized to review the status of primary health care reform implementation in Jimma health center on April 18, 2018 for seventeen participants (three females) from key stakeholders including representatives from the town health office, town administration, local NGOs, SEUHP, and RHB. The family health team’s accomplishments and lessons from PHC reform implementation in Harar were presented by RHB staff. The major gaps identified included poor follow up from the RHB, town health offices, and health center director; transportation problems; absence of fee waiver arrangements per the health care financing implementation manual; interruption of community level services because of security problems; shortage of supplies such as BP apparatuses, stethoscopes, and glucometers; an OPD arrangement that is not in compliance with the urban PHC reform manual; and shortage of health workforce. In response to these gaps, an action plan was developed. Consensus was reached to use the available motorbike to address the transportation problems. The team also provided feedback on PHC reform implementation to the Mayor of Jimma town with

SEUHP FY 18 Annual Report 30 particular emphasis on his role in addressing the shortage of health work force and implementing the fee waiver system.

SEUHP also provided support to Oromia RHB’s effort to scale up urban PHC reform in seven health centers (three in Jimma and four in Shashemene towns) through conducting readiness assessments at the three health centers in Jimma town. The Oromia SEUHP team, in collaboration with RHB and respective town health offices, technically supported basic training on PHC reform implementation at both Shashemene and Jimma towns which was held in mid July 2018. The new seven health centers established a combined 24 family health teams and collected baseline data from more than 80% of catchment households. They are expected to start service delivery by mid-October 2018. As part of logistic support, 88 family health team performance monitoring tools were distributed. SEUHP also procured and provided 10 blood pressure apparatus, 12 stethoscopes, and five glucometers with testing strips to address the shortage of supplies. At the end of June 2018, further follow up was made to monitor implementation of the action plan in Jimma town. The FHTs have resumed providing community level health services and they plan together and monitor performance on a weekly basis. However, the attention given to primary health care reform by the town health offices is still minimal.

SNNPR: PHCR is being piloted at Millennium health center in Hawassa town covering three Kebeles (, Teso, and Guwi kebeles). In this reporting quarter, six FHTs were established, baseline data collection completed, and categorization of HHs based on their health service needs and economic status finalized. Moreover, SEUHP in coordination with the Hawassa THO facilitated progress review meetings at the health center, which were attended by the THO representative; health center director and DPHP team leader, UHE-ps supervisor, and SEUHP representatives. Challenges identified include the lack of convenient work stations for FHTs, lack of tools (bags and documentation materials), absence of close monitoring, and a lack of shared accountability at all levels. To solve some of these problems, the team suggested the health center meeting hall be used as a work station for FHT, that photocopied materials be used to start services, and support be requested from the RHB.

A team of three representatives from the FMOH visited Millennium health center and discussed the FHT’s accomplishments with the health center officials. The action points forwarded following the visit include involving all key stakeholders and working in a collaborative way, periodic review of the progress, provision of intensive technical support, conducting regular supervision and follow-up, and providing kits for the FHT by consulting the Hawassa City Administration Health Department, RHB, and SEUHP. During the second quarter, all the necessary materials including the FHT weekly performance monitoring sheet, FHT referral and feedback slips, and FHT weekly planner book were provided. A half-day orientation was provided on the tools and follow up was made on their use. As a result of the SEUHP teams’ continuous consultative meetings and follow-ups, in the reporting quarter, the health center management has provided office furniture (chairs, tables and cupboards) and stationary for the FHT. Based on the baseline data findings, FHT activity plan, and specific catchment maps of the respective teams were revised and posted on the wall. Shortage of outpatient department rooms, weak engagement of and support from key stakeholders, and lack of transportation and motivation mechanisms for the staff were some of the challenges observed in the implementation process. Worth-mentioning here is that the family health team implementation was seriously affected by the deteriorating security situation that happened at Hawassa. All the UHE-ps and health center staff were busy handling emergency situations though the team is currently being revitalized back to the primary health care reform implementation.

Tigray: In the reporting quarter, HH-level data collection was carried out in one kebele of Wukro town, consisting of 3,710 households using a simplified tool customized to the regional context. Following the household categorization using the collected data, the family health team started to provide comprehensive health services at community level. So far, the FHT provided services for a total of 2,797 people (women and children) including deworming, vitamin A supplementation, antenatal care follow-up and counseling services,

SEUHP FY 18 Annual Report 31 postnatal care services, counseling and referrals for family planning services, and nutritional screening. The FHT also visited five clients with chronic illnesses (such as hypertensive and diabetes mellitus patients) to ensure drug adherence, home-based care, and follow-up services. The family health team used key health messages to educate pregnant women, postnatal mothers and women of reproductive ages, and referred 26 women for family planning, antenatal care visit, and tetanus toxoid vaccination.

In addition, the family health team started school health programs in one school. A total of 15 female and 12 male students, from grade 9 and 10 were selected and educated on teenage pregnancy, consequences, and methods of prevention. The students will serve as primary health care reform champions after receiving subsequent training about the major adolescent health issues and are expected to promote and convey reproductive health messages to the rest of the students in their classes and possibly to other out-of-school adolescents in their neighborhoods.

During the last quarter of FY18, SEUHP regional team organized a day-long performance review meeting on PHCU reform implementation at Wukro town. Twenty-three participants (10 female) from RHB, Wukro THO, and PHCU reform HC attended the workshop. Shortage of staff, lack of regular follow up and technical support from town health office and RHB and health center, and documentation and delay in scale up of urban community health information system were mentioned as key implementation challenges. Meeting participants have developed an action plan that focuses on solving those challenges. In addition, SEUHP facilitated a one-day PHC reform consultative workshop in Wukro town with the aim of facilitating learning from existing experience, identifying successes, and challenges and discussing on what needs to be considered prior to scale up of the reform initiative. Twenty-one participants (nine female) from RHB and PHC reform health center and UHE-ps attended the workshop.

Following the implementation of the PHCU reform, the linkage between health center and UHE-ps, as well as teamwork and community acceptance, has improved.

Table 8: Number of individuals served by the Family Health Teams by region, October 2017- September 2018

Region Number of individuals reached AA 33,924 Amhara 2,751 Tigray 2,656 Oromia 1,231 SNNPR 717 Harar 1,299 Total 42,578

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IR 2 INCREASED DEMAND FOR FACILITY-LEVEL URBAN HEALTH SERVICES

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Sub-IR 2.1 Implement Strategically Designed Behavior Change Communication Interventions

2.1.1 Expand access to and utilization of Information, Education and Communication (IEC) materials and tools focusing on urban health priorities

As part of the effort to improve the quality of services provided by UHE-ps, SEUHP has been providing support to the FMOH in adapting the Family Health Card from the rural HEP and printing and distributing it to UHE-ps and communities for their use during home visits, health development army meetings, and pregnant mothers’ group meetings/conferences. SEUHP has developed different job aids on maternal and new-born child health and WASH and sanitation ladder for use by UHE-ps. Utilization of the different tools and job aids by UHE-ps has been a challenge, which SEUHP has given priority in FY18. Reasons for not using the job aids include: a feeling that lots of job aids and a large number of hard copies of materials, tools and registers to be used by UHE- ps loose ownership and close follow up by the health centers staff on the different job aids utilization where there is no strong accountability for not utilizing of the tools, some job aids are perceived as SEUHP’s material, etc.

Hence, in this reporting period, different activities were performed with the aim of improving utilization of job aids and improving the quality of services.

Harar: Support for UHE-ps was integrated into regular supportive supervision and as one criterion for model family graduation. Orientation was also provided during urban Integrated Refresher Training and participants of the town level implementation workshop focusing on job aids and the reference toolkit provided by SHEUP. Participants included UHE-ps, UHE-ps supervisors and the RHB team. Job orientation was also provided for newly enrolled UHE-ps.

Oromia: During a model household visit, it was observed that although most households with pregnant and under-one children have the Family Health Card, they were not using it properly. To address this gap, the UHE- ps were given an orientation by the SEUHP team on how to properly use the FHS. UHE-ps have started using family health cards during model family trainings and pregnant mother conferences to transfer key health message to clients. They have also begun using WASH and maternal and new-born child health flip charts during health education and counseling services. 25 UHE-ps in Nekemte town had an orientation focusing on how to use job aids in their day-to-day service provision activities. In this reporting period, a questionnaire to assess toolkit use as part of the routine supportive supervision checklist was included. More than 600 family health cards were distributed to UHE-ps at selected Kebeles of Woliso (400 copies) and Shasehmene (206 copies) towns. 3,200 Information, Education and Communication materials and 44 UHE-ps reference tools were distributed to Jimma, Metu, and Woliso towns. A total of 42 UHE-ps from Nekemte, Ambo, and Gimbi towns received on-the-job orientation on the use of toolkits.

SNNPR: Poor use of job aids and behavioral change communication materials, poor handling of job aids during utilization and skill gaps were some of the challenges observed during field visits to UHE-ps. To address these gaps the following actions were taken during the reporting period mainly following the town level UHEP strengthening workshop: reprinting and distribution of UHEP tool kits, strengthen the follow up on UHEP tool kits utilization by health centers, re-orienting of UHE-ps, supervisors and health professionals on identified knowledge and skill gaps on job aid utilization.

Following the town level UHEP implementation workshops, it was observed that UHE-p supervisors have started checking the use of UHEP toolkits and IEC/BCC materials during their field visits to UHE-ps. During the follow- up workshop organized in the reporting quarter, the use of the existing UHEP toolkits received significant

SEUHP FY 18 Annual Report 34 attention from the participants (health officials at the city or town health offices and health centers level), and experts are committed to increase the use of IEC materials and job aids. Some of the action points flagged during the second round of the town level workshop included providing support to UHE-ps to help them understand the English version of the reference tool through supervisors; conducting continuous follow up on the use of the existing UHEP toolkits; identifying major knowledge and skill gaps of UHE-ps on UHEP toolkit use; and re- orienting UHE-ps on identified knowledge and skill gaps.

SEUHP has actively participated in emergency response activities as a member of the Social Mobilization and Health Communication Taskforce established at the SNNP RHB to address the health of Internally Displaced People in Hawassa city (estimated to number14,000) and Gedeo zone (estimated to be 780,000). In line with this, SEUHP supported RHBs (particularly for Hawassa city internally displaced peoples) with WASH IEC materials (2,000 brochures and 35 posters) and provided a half-day orientation for 23 UHE-ps and four supervisors on WASH and priority health problems. In collaboration with other taskforce members, SEUHP disseminated audio messages using mobile vans, displayed 115 A4 size message and banners with health message in two camps (Ethiopia Tikdem and Tabor primary school sites) and provided 24 solid waste storage sacks with labels to each camp with instructions to the Internally Displaced Peoples on how to use them. The messages disseminated include: proper utilization of latrines, hand washing before and after toilet use, proper disposal of kids’ excreta, proper segregation and storage of solid wastes, and proper hand washing before eating or before breastfeeding children among others.

Amhara: The regional SEUHP team assessed the utilization of job aids in UHE-ps’ day-to-day operations. The assessment, despite some variations in the level of utilization, indicated that there was increased utilization in using SBCC materials, other job aids like UHEP service reference tools, and equipment (BP apparatus, thermometer) during home visits and pregnant women conferences. In order to improve job aids utilization, UHE-ps at Debre Markos and Bahir Dar (Hidar 11 sub City) towns arranged weekly peer learning sessions at kebele level. Health center staffs together with UHE-ps also conducted household visits (pregnant mothers & households with under-1 child) to countercheck the utilization of Family Health Card. Similarly, job aid utilization assessment was conducted in integrated with supportive supervision and weekly UHE-ps review meeting. It was observed that those HHs that have family health cards are utilizing them and UHE-ps utilize job aids of WASH, MNCH, and family health card during pregnant mothers’ conference, Integrated Refresher Training to Health Development Armies and their weekly meeting. Besides, UHE-ps reached through follow up visits/supportive supervision in Bahir Dar in the reporting quarter are properly utilizing family health card during household visits and the reference tools while delivering Growth Monitoring services. They are also using maternal and new-born child health tool during counseling of pregnant mothers. In order to further improve the utilization of job aids and toolkit, town health offices and health center staffs included the issue in the action plan developed during town level UHEP strengthening workshop.

Dire Dawa: SEUHP distributed IEC materials (19 banners and 1,500 brochures) to support the City Administration’s effort to combat acute watery diarrhea. These materials were distributed in a targeted manner focusing on high risk communities in the city. In addition, grassroots level communication activities were carried out using vehicles and mobilization instruments. The social mobilization activities were carried out for 12 days, and around 250,000 residents were reached with various messages.

Tigray: SEUHP has been supporting the distribution of job aids and tools to improve the behavior of urban community on key health issues and to increase demand for health services provided by UHE_Ps. The regional SEUHP team provided follow up support on the proper utilization of the tools during service provision at the community level. The team provided orientation for 23 newly deployed UHE-ps in Mekelle town on job aid utilization and Service Data Recording Tools to maintain service quality. Orientation on the utilization of toolkits

SEUHP FY 18 Annual Report 35 was integrated with town level institutionalization workshops in six towns: Mekele, Adigrat, Aksum, Shire, Alamata and Maichew. During the workshop major bottlenecks were identified and key action points identified.

Addis Ababa: Monitoring and technical support was provided during the routine supportive supervision visits on the availability and proper use of job aid materials. New UHE-ps who did not have job aids were provided job aids after the supportive supervision. The new UHE-ps who were not familiar with the tools received on-site orientation during the regular supportive supervision. After the first round town level workshop, there have been improvements on the use of job aid materials by UHE-ps at the household, school, and youth-center levels. Supervisors are also conducting supportive supervision visits with UHE-ps on the use of information, education and communication materials using the standard checklist.

2.1.2 Global Hand Washing Day celebration

SEUHP supported the commemoration of global hand washing day during this reporting period. SEUHP provided technical support by actively engaging in the taskforce organized by the FMOH. SEUHP support included developing the campaign plan, key messages, and campaign materials. In addition, the program also supported regional level initiatives. SEUHP, through its regional team in Oromia, also provided technical support to the development of campaign materials produced to jointly commemorate Global Hand Washing and Global Toilet Days at the regional level and in Shashemane town.

In Amhara region, SEUHP supported a Global Hand Washing commemoration event which was organized in Debre Markos town at Nigus Teklehaimanot primary school on October 19, 2017 and Medhani Alem primary school in on October 7, 2017. Approximately 1,303 people attended the event (three THO officers, two town education officers, five school directors, 43 school teachers, and 1,250 students). During the event, different activities (songs, poems, drama, question and answer) were performed or presented to the audience. In Debre Birhan, 792 people participated in the event, including 33 teachers (26 female) and 659 students (341 female) students.

The Oromia regional team printed 72 banners with key health messages in Oromiffa for the regional level Global Hand Washing and World Toilet Day commemorations that took place in Tefki town of Sebeta woreda on November 21, 2017. The event was attended by 1,537 people including representatives from the Council of Aba Geda, regional government staff and partners, regional police officers, Tefki town residents, Sebeta woreda health staff, Tefki primary school students and teachers, and health extension workers. The event in Shashamene was also attended by more than 750 participants including the town’s mayor.

SEUHP technical support has contributed towards making these events platforms to increase awareness on the importance and contribution of hand washing to health and to encourage stakeholders at different levels to play their role in encouraging hand washing practices, making WASH facilities accessible, and promoting personal hygiene.

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Sub IR 2.2. Produce and Air Radio Programs to Promote and Model Key RMNCH, HIV/AIDS, TB, and WASH Related Behaviors

2.2.1. Air radio magazine program to promote key RMNCH, HIV/AIDS and WASH behaviors

In FY 16/17, SEUHP initiated the airing of a 15-episode radio magazine program in all Amharic and Oromiffa speaking target towns and collaborated with the Tigray RHB to produce the magazine program in Tigrigna. In this reporting period, the program was aired via Fana 94.8 covering Harar and Dire Dawa and also covering parts of Oromia and Somali regions. The production of the radio program in Tigrigna was also finalized and aired through Dimtsi-weyane FM radio 102.2.

According to the feedback obtained through the radio magazine tracking/monitoring sheet, the audience from various towns indicated that listeners gained better understanding and information on major health issues, and it helped them to adopt healthy behaviors. Similarly, SEUHP in SNNPR received a summary of feedback from the audience of the Malefia radio magazine program. The feedback was mostly positive and showed that the program is highly targeted, presented in an entertaining manner with valuable information, and addressed the government’s focus health issues. Feedback from the radio station journalists also attested that the Malefia radio program was catchy and audience-oriented. Feedback from Fana FM 94.8, which broadcasted the program, also indicated encouraging results in terms of listenership.

2.2.2. Produce and air 26 episodes of serial radio drama

SEUHP started developing a 26-episode radio serial drama in Amharic. The serial drama aims at promoting healthy behaviors and encourages audiences to model the behaviors of the characters, whose stories listeners follow as they struggle and overcome common challenges. The production of the radio serial drama was finalized in this reporting period. Currently, the program is on air every Friday at 11am in the morning using Ethiopia National Radio Station that has wide national coverage.

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

In FY17, SEUHP provided support to select regional level media engagement activities to strengthen the collaboration between media outlets and RHBs in addressing health needs of communities they serve by focusing on urban health challenges and promoting healthy behaviors. The support provided included setting priority agendas to be communicated; preparing resources aimed at enhancing media coverage of prioritized health challenges; and organizing media engagement workshops to initiate collaboration platforms and to orient journalists on current government health priorities/agenda.

Addis Ababa: During the reporting period, SEUHP supported the Addis Ababa City Administration’s Health Bureau in organizing the third and fourth media engagement workshops which brought together representatives from 13 different digital and print media companies. The objectives of the workshops were to review the progress of the media in implementing the activities planned during the previous workshops, update media personnel on major urban health priorities and programs, and devise solutions to challenges faced by the collaboration forum. Addis Ababa Health Bureau made a presentation to equip participants with information on the priority urban health topics. Media company representatives also gave updates to participants on the different urban-focused activities they carried out during the reporting period following the previous workshop.

The media engagement platform which was established in Addis Ababa, has celebrated its one year anniversary during the fourth regular review meeting that was attended by thirteen media companies (Ethiopian Herald, Addis Zemen, Addis Lisan, Fana FM, Addis TV and FM 96.3, FM 97.1, Zami FM, Sidist Meazen- Health, Ethio-FM 107.8, Sheger FM, Addis Admas and Ahadu FM, Addis Ababa Communication Office) and the Addis Ababa RHB Communication Office).

Issues covered during the review meetings include UHEP, primary health care units, model health centers, School WASH programs, Global Hand Washing Day, solid and liquid waste management, school health, Maternal and Child Health, Healthy Maternity Day, Community tuberculosis screening and referral, HIV/AIDS, , Adolescent Youth and Reproductive Health services, nutrition, non-communicable diseases, and occupational health.

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Table 9: Contribution of media in promoting urban health issues in Addis Ababa, October- December, 2018 Media agency Type Type of Issues addressed program Addis Zemen Print Health column  Solid waste management practice in Addis Ababa, its associated News column health and environmental problems, and possible solutions including recycling.  Malnutrition, its effect and government response. Addis Lisan Print Health column  World AIDS day. News column  The current status of HIV prevalence in Addis Ababa, including most vulnerable population groups and targeted services to reach this group.  MNCH services in the primary health care units and the challenges related to service quality.  SEUHP-initiated Leadership Management, and Governance, its result.  The ultrasound donation from JSI to Nifas-silk Lafto Wpreda-10 health center was covered. Addis Admas Print Health column  Proper latrine utilization of households in Addis Ababa.  “Hidar Sitaten,” a traditionally known program about sanitation Wanaw Tena Broadcast Air time-radio campaign taking place every year on November 21. Radio Program (FM) program

Ahadu Radio  “HIV the current challenge of Addis Ababa.” This program addressed the increase in prevalence following the interruption or loosening of interventions in the past few years. FM 98.1 Broadcast Fenote Tena  The UHEP has been addressed in the Fenote Tena air time. The (FM) overall UHEP service package has been discussed including major activities of UHE-ps. Referrals and linkages, treatment defaulters, TB suspect screening, pregnant mother’s identification and follow-up, neonatal and child health practices in public health facilities, solid and liquid waste management of hotels and industries and health centers have been addressed. Addis Ayne Print Health column  This program mainly addresses the challenges of women that Magazine are living on the street. Reproductive health and related health Sheger FM 102.1 Broadcast Yimesh- Women problems including HIV and sexually transmitted infections were empowering the main agenda both in the magazine and radio program. program SidistMeazen Broadcast Health air time-  The program addresses HIV for ten minutes of air time every (Abay FM) (Abay FM One of the angle week. Tuberculosis prevalence in Addis Ababa, the reasons why 102.9) is health it remains a challenge for urban population, and its recommended prevention practices have been address by a serious of programs.  Solid and liquid waste management practices in Addis Ababa and adolescent and youth challenges in universities were also the major health issues addressed on the program. Zami 90.7 FM Broadcast “Liyou Gebeta”  HIV was one of the main program areas in the past four months Radio due to its increasing prevalence in the city and updated service (LiyouGebeta packages including the new HIV test algorithm. Radio Program)  The other program was about the exempted and waiver fee health services in primary health care units for underserved (poor) community.

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 The waste management practice in Addis Ababa and lessons learned from the case of Koshe was also aired.  Pharmaceutical stoke management and community nutritional knowledge and practices have been addressed in the past four months. Ethiopian Herald Printing Health Column  Since this is a magazine printed in English, the general public is Magazine not targeted. Issues that require higher level decision making were given coverage.  “Not to waste the waste” was a column about how to minimize, handle, and recycle waste at all levels.  Hazardous waste management, occupational health and safety practices, and HIV programs were also addressed.  “Curbing the misuse of Antibiotics” was another program produced in this magazine. FM 97.1 Broadcast Health programs SEBEZ Media Broadcast Health programs  Hand washing practice (SEUHP facilitated an interview with the (Ahadu Radio) WASH expert from the FMOH). AARHB Print and Health  The Addis Ababa health Bureau communication office mainly Communication Broadcast uses Addis TV and FM 93.6 to do programs and news about all Office issues related to public health services available at public health centers and hospitals. In the past four months, different programs have been produced with a special focus on the UHEP including the series of training sessions provided by health bureau on Integrated Refresher Training for UHE-ps and Leadership, management and governance for selected primary health care unit implementing health centers. Other program activities including community tuberculosis screening and linkages have been addressed.

Dire Dawa: A three-day UHEP implementation manual and WASH focused training was provided for 26 different media communicators. This training was organized by the RHB with technical support from the regional SEUHP office. The first objective of the workshop was to build knowledge of the media personnel on the revised UHEP Implementation manual and WASH related priorities of the RHB. The other objective was to train the media communicators on how to connect the community, health centers and the RHB with the aim of solving community health problems. The participants’ pledged to develop an action plan to cover the issues.

Amhara: SEUHP continued to support the 24 media professionals from Fana Broadcasting, Amhara Mass Media Agency (radio, TV, and print media), and Ethiopia News Agency (ENA) trained in FY17. Following the training, Gondar Fana FM 98.1 promoted urban sanitation and hygiene and UHEP services through a one-hour program. The town’s Health Extension Program officer, a UHEP, and a SEUHP team member were guests on the program and used the opportunity to promote urban health issues and services provided by UHE-ps to the audience.

During the third quarter, the Amhara regional SEUHP team, in collaboration with the Regional Health Bureau and Amhara Mass Media Agency, conducted a day-long media performance review and planning workshop. Twenty participants (six females) from Fana Broadcasting, Amhara Mass Media Agency, and Ethiopia’s News Agency attended. Each media representative presented what they had achieved since the media professionals training conducted in the previous implementation period. An action plan was prepared for next year and submitted to the RHB for joint follow up on implementation.

The following are the major achievements per the presentations during the review meeting:

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Table 10: Contribution of media in promoting urban health issues, October 2017-Septmeber 2018

Media agency Issues addressed Amhara Mass  Developed program on personal hygiene which was televised on regular children’s programming Media Agency for 15-20 minutes.  Developed three programs on Acute Watery Diarrhea and hygiene issues which were broadcasted on the “Miker Behakimewo” regular program.  Bahir Dar city waste management system created and broadcasted a video on urban waste management.  Documented problems related to abattoir services in Bahir Dar and shared with communities via a news program.  Aired a news piece on the issue of health institutions’ WASH facilities.  Aired a news piece on the liquid waste management system of town. Bahir Dar FM radio  Transmitted three programs on waste management problems and solutions.  Developed three live discussion programs on the cause of Acute Watery Diarrhea and their solutions with religious leaders, health professionals, the beautification office and the water and sewerage utility offices.  Developed 30-minute program on hand washing and aired to communities twice a week.  Developed 20-minute program about slaughtering waste management system and aired to communities a day before holidays.  Developed program about urban health extension program and aired to communities. Amhara Radio  Developed live program for communities on urban health extension program and invited health professionals to provide professional explanations about the existing UHEP services.  Developed programs on the urban waste management system at Finote Selam, Woldia, Gondar, and Debark towns and aired in health programs.  Developed live discussion programs on Acute Watery Diarrhea outbreak associated with Andasa holy water and their solutions with participation of religious leaders and health professionals. Bekur Newsletter  Developed seven articles about personal hygiene, hand washing, waste management and food and drinking establishment, latrine cleanliness and use, and solid and liquid waste management system. Ethiopia News  Developed five news pieces on shortage of water supply and impacts on health institutions; five Agency news pieces on urban waste management, problems, and their solutions. Fana Broadcasting  Broadcasted 38 news, three spots, and five online discussion programs about Acute Watery Corporation (FBC) Diarrhea and personal and environmental hygiene practices and health benefits.  Developed 15 news pieces and two live discussions forums about latrine construction and use.  Developed six news pieces, one spot, and two live discussion forums about the impacts of the health extension program on WASH.  Developed 8 news pieces, one spot program, and one online discussion about the current problems with urban waste management and possible solutions.

SNNPR: Following the three successive media engagement workshops carried out to enhance the capacity of media personnel on urban health content/program development in the last two quarters of FY17, the team continued to technically support the RHB. In this quarter, the RHB printed 60,000 copies of two posters by investing around 380,000 ETB. Additionally, the five radio spots broadcasted in FY17 were translated into 15 local languages used in the region and broadcasted twice a day for four months (From October 1 – 16, 2018) on FM 100.9 stations at a cost of close to 1.2 million Ethiopian Birr and reaching audiences in Benssa, Bonga, Fesehagent, Waka, Jinka, Hosanna, , Wolkite, and parts of Oromia. These behavioral change communication materials will greatly contribute to the RHB’s efforts to revitalize the audiences’ commitment to continue to fight the spread and impact of HIV/AIDS.

On the other hand, following the National Urban Health Conference that took place in April, 2017, SEUHP in collaboration with the Ethiopian Broadcasting Services (EBS), a private television channel, has produced documentary films on Urbanization, Urban Health Extension Program and WASH. After getting approval from

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USAID the two documentaries on Urbanization and Urban Health Extension program were aired on July 25 and 26, 2018 while the two episodes on WASH were transmitted on July 31 and August 1, 2018. The main purpose of the documentary films was to create awareness among the society about urban health, urbanization and its effects. These documentaries will be distributed to Regional Health Bureaus so that they can use them to create demand by airing them using the local or regional media. Besides, it’s planned to upload the films on YouTube to avail them for those who are interested.

Sub IR 2.4: Urban Champions Enlisted to Help Promote Health

Engaging urban champions as a vehicle to promote urban health issues has been identified as one of the most important strategies used in strengthening the implementation of urban health activities. SEUHP planned to enlist a total of 100 champions from different communities and to utilize them for the promotion of different health issues. These champions have been working together with UHE-ps through different means. Some of the major contributions of these champions include: working with/ support UHE-ps in mobilizing the community during health and sanitation campaigns; improved the health service seeking behavior of their community through awareness raising activities;, initiating and creating clean & green areas through mobilization of their village community; and giving care & support to PLWHIV & elders among others.

In this reporting quarter, 107 community health champions who have been enlisted from all SEUHP implementing towns in all the seven regions and city administrations were recognized for their significant contribution on health service and WASH activities through provision of certificate at different forums including during WASH platform workshops. The certificates are meant to motivate the health champions to continue their current engagement in health service activities and will serve as exemplary members of their communities to motivate others to engage in such useful contributions.

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IR-3 STRENGTHEN REGIONAL PLATFORMS FOR IMPROVED IMPLEMENTATION OF THE NATIONAL URBAN HEALTH STRATEGY

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Sub IR 3.1: Improve Institutional and Managerial Capacity of Urban Health Units at Regional Health Bureaus, Zonal Health Departments, Town Health Offices

3.1.1 Provide technical support to regional health bureau, town health office, health center staff to develop tailored and context-specific work plan based on the revised UHEP implementation manual

The SEUHP team, together with city or town health offices, has been providing technical support to UHE-ps in developing their own work plans with realistic targets and updating their plans based on regular performance monitoring through the woreda-based plan. In addition to the technical support, the SNNPR SEUHP team provided flip charts and markers to each UHE-p office at the kebele level (91 kebeles). As a result, each UHE-p office has an annual work plan with updated catchment population profiles posted on the walls of their offices.

The Oromia SEUHP team provided technical support to Asela, Adama, Nekemte, Ambo, Negele Borena and Shashemene town health offices and primary health care units on updating their annual work plans based on the Balanced Score Card approach and in ensuring the use of the revised implementation manual while setting specific targets on referrals, HIV testing and counseling, family planning, health education, nutritional screening, and pregnant and under one registration and follow-up. With this effort, all UHE-ps in the two towns have up-to- date individual and aggregated kebele-level work plans with wall charts including a performance monitoring chart, population profile, and catchment map.

Through the technical support of SEUHP in Bahir-Dar, Debre-Markos and Finot-Selam (Amhara region), health centers and UHE-ps developed their annual work plans for the year 2011 Ethiopian Fiscal Year (EFY). Likewise, all UHE-ps in Harar received technical support in developing their own annual work plans and latest catchment population profiles for their respective kebeles. Wall charts were also revised and rearranged accordingly. The FHTs at Jinnelle, Aboker and Amirnur health centers planned their activities using household categorization based on the revised UHEP implementation manuals. Though the level of transition varies from place to place, the HH categorization approach is being implemented in 10 health centers in Addis Ababa, one health center in Harar, one health centers in Jimma, one health centers in Wukro, one health center in Hawassa, and one health centers in Bahir Dar.

SEUHP in collaboration with Addis Ababa RHB organized workshop to develop the annual work plan for the 2011 EFY from August 23 to 25, 2018 in Adama. In that workshop, before the annual planning session, the performance report for the 2010 EFY was presented and discussed. After the performance report presentation, the annual plan for the 20111 EFY was developed by each sub-city health office and presented and discussions were held after every presentation to enrich every plan further as per the revised UHEP implementation manual. In the annual planning workshop, a total of 53 participants from regional and sub-city health offices attended; 8 from Addis Ababa RHB UHEP case team officers, five from SEUHP Addis Ababa regional team staff, ten from sub City Health Promotion and Disease Prevention core process leaders and 30 from sub City UHEP officers had participated in the workshop.

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3.1.2 Conduct leadership, management, and Governance (LMG) capacity enhancement for Regional Health Bureau, Zonal Health Department, Town Health Office, and Health Center staff

LMG training aims to enable urban health leaders to identify and fill gaps that have hindered the effective implementation of the UHEP. The training is designed for health care providers and health workers and is believed to improve work climates, management systems, individual responsiveness to change, and the delivery of high-quality health services in an equitable manner to ultimately improve health outcomes.

Witnessing the results observed at SEUHP’s sites that applied the Leadership, Management and Governance (LMG) initiative, the SEUHP team along with the FMOH customized the LMG training module for WASH stakeholders in this reporting period. The customization was done in consultation with the FMOH HR department, FMOH WASH team, and LMG-trained FMOH staff. The FMoH’s human resource department participated in orienting the working group from JSI and FMOH and facilitated the customization process. The department has agreed to review the document to standardize and make it a national document. The training manual has three modules: Module 1: Hygiene and Environmental Health Service Delivery Situations, Policies, Strategies, and Programs in Ethiopia; Module 2: Leadership, Management, and Governance for Hygiene and Environmental Health; and Module 3: Resources Management.

As a continuation of the 2017 LMG training, Harar and Dire Dawa facilitated the second, third, and fourth rounds of LMG trainings for health workers. In Harar 29 participants (14 males and 13 females) attended the training, and in Dire Dawa 44 participants (20 males and 24 females) attended the two rounds of training. In Addis Ababa, SEUHP also provided technical support in organizing two rounds of LMG training as the request of the AACA- RHB. The training cost was covered by the RHB and the training was initiated following the promising results observed at SEUHP-supported sites. A total of 105 individuals from Amoraw and Gerji health centers (Bole Sub- city), Woreda 6 health center (Nefas Silk Lafto Sub-city), and Entoto #2 health center (Yeka Sub-city) attended the two rounds of training. In Amhara region, the Han Health Center at Bahir Dar faced high turnover of staff and key coordinators, including the health center directors, which created a gap in the implementation of the skills and knowledge gained from the LMG training. In response to this, the SEUHP team organized a one-day workshop for 27 Han Health Center and city health office staff to refresh previous trainees’ knowledge and introduce the training to new staff. Based on the remarkable achievements of the LMG training, the Addis Ababa RHB has expanded the LMG training and coaching initiative to four more health centers: Nifas-Silk Lafto sub-city Woreda 06, Yeka sub-city Entoto number 2, and Bole sub-city Amoraw and Gerji health centers.

SEUHP regional teams in Amhara, SNNPR, Tigray, Oromia, and Addis Ababa conducted post-training follow-up visits and coaching for health centers that took LMG training. Some of the activities performed and strategies used to enhance the achievements include demand creation, community mobilization and enhancing counseling services, strengthening the weekly pregnant women’s conference, monthly progress review, establishing good relationships with UHE-ps, enhancing community referrals, facility-level targeted screening, proper management of client cards, initiating and strengthening home-based postnatal care services through UHE-ps and family health teams, improving linkage and team spirit of UHE-ps and health center staffs, timely notification or linkage of mothers who give birth at health facilities with UHE-ps, and improving the quality of counseling services through on-the-job training, among others.

In Tigray region to institutionalize the LMG initiatives in Semen (Mekele) and Millennium (Aksum) health centers three rounds of training has been provided, and in this reporting period follow up visits have been conducted to these health centers. Some of the major improvements observed at these health centers include: the commitment of health centers’ staff have been improved in identifying the major prevailing challenges in their

SEUHP FY 18 Annual Report 45 respective health centers and solutions were sought; regular monthly meetings to discuss challenges and how to resolve them; linkage and the working relationships improved between health centers’ staff and UHE-ps; best performing staffers of health centers were recognized so as to motivate the staff; health centers’ staff have been technically more supportive to UHE-ps in identifying pregnant mothers and estimating the expected date of delivery so as to enroll pregnant mothers into focused antenatal care services and in ensuring institutional delivery; and the referral and feedback services between health centers and UHE-ps have been improved.

Major achievements observed at the LMG sites include the following;

. LMG promoted shared vision, accountability and transparency, motivation, and healthy competition among staff members. . LMG promoted intra- and inter-referral/integration between health professionals and services and facilitated teamwork/team spirit. . Helped to improve yield (HIV positivity) from HIV testing and counseling. . At Han health center in Bahir Dar, postnatal care uptake increased from 17% in January 2018 to 66.3% in March 2018 (Target=80% in June 2018). . Helped in establishing home-delivery-free forum and conducting quarterly review meetings at the health center level with community leaders, religious leaders, opinion leaders, women and children’s affairs offices, kebele leaders, and UHE-ps. . Strengthened pregnant women conference on monthly basis with UHE-ps and Kebele leaders at the kebele level and quarterly at the health center level with UHE-ps and health center staff. . Helped in decreasing patient waiting time (e.g., at Alamura health center -SNNPR the waiting time between triaging and receiving outpatient department services is decreased from 35 minutes to 15 minutes; time for payment for services is decreased from 30 minutes to 10 minutes). This has improved patients’ satisfaction and utilization of the health center. . Increased tuberculosis detection rate through enhancing community referral and facility-level targeted screening (e.g. from 20% in July 2017 to 87.5% in March 2018). . Improved community level TB suspect, identification and case detection rate at Entoto #2 health center from 0 to 15% between. . Helped in increasing completed referrals (e.g., from 40% to 68% at Alamura health center in SNNPR) through strengthening health center to kebele/UHEP linkage, use of non-financial incentive mechanism for well performing UHE-Ps regarding referral feedback collection and documentation, and assignment of referral focal persons for each kebele and referral service. . Increased home-based HIV testing and counseling (e.g., at Debre Markos health center from zero to 67.5% between December 2016 and May 2017; the target was to achieve 30% by June 2017). . Increased the administrative coverage of the fourth antenatal care visit (Percent of fourth antenatal visit at Abosto health center at Shashemene town increased from 45% in September2017 to 75% in December 2017). . Increased institutional delivery (e.g., Semien health center in Mekele increased institutional delivery from 24% in 2009 EFY to 33% in the first half of 2010 EFY). . Increased data quality in selected health centers (Increased data completeness and accuracy from around 50% in September to 95% in March 2018 at Abosto health center -SNNPR.)

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3.1.3 Conduct city/town health office level comprehensive workshop to support institutionalization and sustainability of SEUHP activities into GOE’s Health System

Building the technical capacity of city/town health office and health center staff in all components of the UHEP greatly contributes to successful UHEP implementation and is also expected to ensure institutionalization of SEUHP-supported activities in the healthcare system. Hence in FY18, SEUHP organized two-day town-level comprehensive institutionalization workshops in all of 49 town health offices supported by SEUHP.

The major objectives of the town level workshops were:

. To create better understanding of the revised UHEP implementation manual and identify key implementation bottlenecks. . To discuss challenges to and solutions for use of different tools and job aids used for UHEP. . To identify key challenges and set possible actions for urban health program monitoring, reporting, and data use.

First round workshops: In FY18, the workshops took place in all the seven SEUHP-supported regions/cities. A total of 1,109 participants attended these workshops. The participants included Health Center medical directors, supervisors, UHEP focal persons, representatives of city/town health office, Health Promotion and Disease Prevention Core Process leaders, WASH officers, and representatives from RHBs, among others. The workshop employed slide presentations, group sessions, and plenary discussions with the leadership of representatives from Regional Health Bureaus, sub-city health officials, and city/town health offices. To standardize the workshop approaches, a workshop guideline and initial presentation slides were shared with each regional SEUHP team.

The major topics covered during the workshops include SEUHP collaborations and accomplishments, the revised UHEP Implementation Manual (reviewing its current implementation status and familiarization of the approaches of the UHEP, UHEP Implementation Packages, roles and responsibilities), overview of UHEP tools and utilization of the UHEP Implementation Toolkit, routine data collection, management and reporting, and supportive supervision. For each of these topics, the current implementations status, implementation challenges, and the way forward were covered and action plans were developed. Some of the key activities implemented by the respective government offices based on the action plan developed during the institutionalization workshop are summarized in the table attached as Annex 1.

Some of the key benefits of this workshop included;

. Engagement of key UHEP personnel: The workshop brought together Regional Health Bureau, City/Town Health Office, and Health Center level UHEP staff to have a focused discussion on the UHEP and how to improve implementation through proper understanding and ownership of their roles in implementing the program at all levels.

. Enhance capacity of existing and new City/Town Health Office staff on UHEP: Staff turnover, gaps in understanding of the revised UHEP manual, and lack of clarity around the roles of officers at different levels were identified as challenges to fully implementing UHEP. The workshop addressed these gaps by enhancing the capacity of UHEP staff at different levels in areas such as UHEP, revisions made in the revised manual, roles and responsibilities, and different program tools and their role in ensuring optimal utilization.

. Identifying challenges and devising actions to improve implementation of the national Urban Health Program: Each session of these town level workshops included activities aimed at identifying bottlenecks/challenges to program implementation and utilization of program tools and

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developing coordinated and shared action plans to address the challenges identified at regional, City/Town Health Office, and Health Center levels. During the workshop, these outputs were presented and endorsed by participants. The revised plans were later refined and endorsed by the respective City/Town Health Office and communicated to participants for implementation. All activities planned will be implemented and financed by the respective Regional Health Bureau and/or City/Town Health Office and/or Health Centers.

. Identification of focus areas for support: The sessions have created clarity with regards to the type of support (technical, leadership, administrative, and supply) UHE-ps and the program requires from the City/Town Health Office and Health Center. SEUHP also used this opportunity to further refine its area of support for the remainder of the project.

. Utilization of job aids: The workshops have exposed essential UHEP staff to the different job aids provided by the program for improving the quality of services UHE-ps provide and for creating an understanding of what supervisors’ roles are in ensuring UHE-ps optimal utilization during service provision. To address challenges observed in use of the job aids among some UHE-ps, participants have integrated activities into their action plans including integrating observation items in supportive supervision checklists and preparing reminders for supervisors.

. Addressing challenges related to monitoring and In Amhara region, following the town level data utilization: During the workshop, participants workshops, the implementation status of the identified challenges to data gathering and use at different action plans developed in every town during levels of the system and how they can improve until the town level workshops were closely FMOH provides guidance on Health Management monitored by SEUHP in collaboration with Information System and/or Community Health Management the RHB. During the visits, it has been Information System. Key actions planned include addressing observed that the duty stations of all UHE- gaps in the Service Data Recording tool to meet respective ps in the region were shifted from Kebeles data needs, following up on the timely collection of data to Health Centers. Such changes facilitated: using the service data recording tool, and using the data timely provision of technical assistance to generated for planning and performance management. UHE-ps from the Health Centers’ staff, . Making UHEP tools accessible for future use: As part timely refilling of supplies, timely submission of the effort to transition different tools developed through of reports from UHE-ps to Health Centers, the collaboration of SEUHP and FMOH/RHBs, electronic improved data collection timeliness and versions of all tools, job aids, and other essential verification, and improved data quality. documents were compiled and distributed (one copy per health center/ City/Town Health Office) for reproduction in the future.

Follow up visits: The post-workshop follow-up visits and updates indicate the workshop has contributed in strengthening the town level implementation of the UHEP. Some of the changes observed following the translation of the action plans developed during the workshops include the following:

. Workshop participants have created forums to share the action plans developed during the workshop to the rest of Health Center staff members. They have also provided orientation on the revised UHEP Implementation Manual. . In many towns, including the whole of Amhara region, the duty station of UHE-ps was relocated from the sub-city or Kebeles to the Health Centers. This will allow HC staff and UHE-ps to work together more

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closely, strengthening the linkage between the roles through technical support such as weekly meetings and joint household visits. . Health Centers started providing supplies to UHE-ps (e.g., Amhara, SNNPR, Tigary, SNNPR) using the government’s IRRF form and stock outs are being refilled through this system. . HCs are assigning technical staff and supporting UHE-ps on a weekly basis per the revised UHEP implementation manual (e.g., Alamata, Maichew, Mekelle, Aksum, Bahir Dar, Hossana, Hawassa, Adama, Bishoftu, and Nekemte). . Service provision is being implemented through the categorization of households with Category IA and Category IIA Households given the priority to be visited by UHE-ps (e.g., Addis Ababa). . Towns are taking timely actions in filling vacant UHE-ps posts by allocating budgets. . Supportive supervision tools have been revised and customized to local contexts (e.g., Alamata, Maichew, Hossana, Addis Ababa) and supportive supervision is being carried out using simplified structured checklists adopted from SEUHP and have become regular and provide timely feedback. . Knowledge and skill gaps of UHE-ps have been improved through on the job capacity building activities . UHE-ps became familiar with toolkits and utilization has improved as a result of the technical support provided by UHE-ps supervisors from Health Centers. . Data collection, management and utilization showed significant improvement at all levels . Health offices and Health Centers have started conducting separate regular review meetings for UHEP by mobilizing resources which previously used to be neglected by giving more priority to the facility level services. . The UHEP automated report generation tool has been developed and currently all health centers in SEUHP supported sub-cities of Addis Ababa are using the tool. . UHE-ps, primarily in Addis Ababa, have started providing direct services they were not previously allowed to provide, including postnatal care, short-term Family Planning, diabetes mellitus screening, iron foliate supplementation, HIV Testing and Counseling, and services for hard-to-reach population groups and workplaces. . Health centers and sub-city health offices are conducting bi-annual, quarterly, and monthly review meetings in regular basis. . Linkage and collaboration between UHE-ps and the Health Development Armies showed improvement.

Lessons Learned from the town level workshops:

. Engaging key decision makers from relevant stakeholders in UHEP review meetings is very important to easily address issues that need multi-stakeholder’s engagement. . Capacitating health center professionals to support UHE-ps is essential. . Action oriented workshops bring significant change in short period of time. . The follow-up workshops created important experience sharing and learning opportunities for stakeholders involved in implementing the urban health extension program. . There is a need to improve inter-sectorial collaboration and involvement of key community members at all levels during planning, executing and monitoring performances (like during conducting review meetings)

The regional level version of the institutionalization workshop was also conducted in Dire Dawa for one day. A total of 32 people (24 males, and 8 females) took part in the workshop. More emphasis was given to WASH and Primary Health Care Unit Reform (PHCUR) and field visits were also conducted to solid waste collection sites and the PHCUR implementing Health Center and community. The major challenges identified during the field visits include: shortage of human resources for PHCUR, weak inter-sectoral collaboration, existing security

SEUHP FY 18 Annual Report 49 concerns in the region, existing gaps in collecting the solid waste on time, the low level of salary being paid to solid waste collectors, and a lack of resources such as gloves and gowns for solid waste collectors.

3.1.4 Conduct coaching skill training for UHEP program officers and supervisors

Following the training of trainer that was held in FY17 on coaching skills, most SEUHP regions have cascaded the training in their respective regions, and have started implementing the coaching scheme. The Amhara team has gone on follow-up visits to HCs who have taken the training. Ginbot 20 Health Center in Bahir Dar has assigned five Health Center staff members trained on coaching to mentor UHE-ps. HC staff have started doing structured visits by using checklists during field visits. They provide written feedback with an agreed-upon action plan signed by supervisee and supervisors. Similarly, Shimbit Health Center in Bahir Dar has assigned two trained Health Center staff to support UHE-ps in the community. They are conducting regular visits to UHE-ps. Overall, Health Centers have started coaching UHE-ps in accordance with the coaching skills training they received.

The Oromia SEUHP team also followed up on the coaching training, which has been cascaded in Jimma. The follow-up visits conducted by the Jimma cluster coordinator showed that nearly all HC staff who received mentoring and coaching training has been providing regular support to UHE-ps. The achievements observed include improved referral linkages and referral feedback documentation, improved defaulter tracing and linkages, improved availability and utilization of supply and medical equipment, and frequent household visits. The changes are attributed to proper documentations of referrals, the development and utilization of a simple format for tracking defaulters, regular and continuous follow up, regular monthly review of activities, and strong leadership at the Town Health Office and PHCU levels.

3.1.5 Support regional health bureaus to conduct integrated supportive supervision in urban areas

Integrated supportive supervision falls under the jurisdiction of Regional Health Bureaus and is a necessary step to ensure and monitor the quality of services delivered within government health facilities and at community level. ISS is also needed to strengthen referral systems and coordinate linkages between health facilities and community services. Integrated supportive supervision supports service providers in achieving their objectives and plans by improving their performance, ensuring uniformity and compliance with pre-set standards, identifying and solving problems in a timely manner, following-up on action points from previous supervision visits, identifying staff needs, providing opportunities for personal development, and reinforcing administrative and technical links between higher and lower-level structures. As part of this effort, SEUHP has been providing technical and logistical support to Regional Health Bureaus in planning for integrated supportive supervision visits, reviewing checklists, supporting the execution of integrated supportive supervision, and preparing and implementing action plans based on the feedback from the integrated supportive supervision.

In previous years, SEUHP regional teams were the ones to initiate joint supportive supervision to enable the Regional Health Bureau HEP case team to support towns with UHEP implementation. The UHEP has been overlooked during ISS and annual review meetings organized by the bureaus. With the aim of ensuring ownership and strengthening institutionalization of the program, in this reporting period, SEUHP’s Amhara regional team held discussions with M&E and Health Promotion and Disease Prevention process leaders at the RHB and agreed to adopt the SS checklist that was developed and has been used by SEUHP for the ISS. The regional SEUHP team translated the supportive supervision checklist into Amharic and provided it to the Regional Health Bureau. SEUHP also participated in the checklist revision workshop held December 17-19, 2017 and finalized all the Household, UHE-ps, Health Center, and City/Town Health Office supervision checklists. An ISS team was organized to support UHEP during the reporting quarter and conducted supportive supervisions to Bahir Dar,

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Gondar, and Dessie towns using the revised checklist. SEUHP was part of the urban ISS team and provided technical support on how to use the checklist by demonstrating it in the field. SEUHP also provided vehicles to the RHB to conduct ISS. The activity is one of SEUHP’s significant achievements in terms of institutionalization of the checklist within the regional health system. Ideally, ISS should be conducted on quarterly basis.

Integrated supportive supervision was also conducted by the Disease Prevention and Health Promotion experts at the SNNPR Regional Health Bureau jointly with the SEUHP regional team in Wolayita Sodo zone. The visits aimed to support WASH, EPI, malaria, and TB/HIV activities at PHCUs, health posts, and household levels using pre-prepared checklists. The integrated supportive supervision used the standard supervision checklist adapted from the SEUHP tool during the town level workshop.

Similarly, the Harar SEUHP team provided technical support for the ISS conducted in six woredas with the RHB staff, including the head of the RHB. The supervision covered households, Health Centers, and woreda health offices, including UHE-ps. In Addis Ababa, SEUHP’s regional team provided technical and logistic support for AACAHB while conducting integrated supportive supervision at eight Health Centers and four schools. The team also participated in the revision of SS checklist. In Dire Dawa, SEUHP in collaboration with HEP Officers from the RHB conducted integrated technical supportive supervision to Health Centers, UHE-ps and their using a standard Supportive Supervision checklist developed by SEUHP and adopted by RHB.

3.1.7 Provide targeted technical support to City/Town Health Offices and Health Center and help them conduct regular supportive supervision to UHE-ps and/or their supervisors

In FY18, SEUHP continued supporting selected City/Town Health Offices and Health Centers to conduct regular supportive supervision for UHE-ps at City/Town Health Offices, Health Centers, and kebeles/woreda levels aimed at improving UHE-ps’ capacity to deliver high-quality services. Between October 2017 and March 2018, SS visits were conducted with UHE-ps, UHEP supervisors, Health Centers, and City/Town Health Offices in Amhara (12 towns), SNNPR (11 towns), Oromia (14 towns), Tigray (7 towns), Dire Dawa, Harar, and Addis. The SS was done with Zonal Health Department officers, City/Town Health Offices, and Health Center staff members. A total of 3,343 (2,873 UHE-ps and 630 supervisors) received supportive supervision visits. The onsite support focused on current service provision practice guidance; adherence to the standard practice of making referrals and linkages to health services; building rapport with beneficiaries and assessing needs; proper implementation of the service data recording tool; and reporting.

Observations from household visits showed that the awareness level of individuals regarding maternal and child health, prevention of communicable and non-communicable diseases, utilization of bed nets, and utilization of facilities (latrine & solid waste disposal) is improving. Observations also showed that the list of pregnant mothers and under 1children is being captured by Health Development Armies and their report to UHE-ps when there are antenatal care and EPI defaulters and TB suspects.

Positive findings observed during SS visits include: . Minimum standard wall charts updated and posted (population profile, kebele map, and quarterly performance monitoring charts). . Updated basic population profile of the catchment populations including vulnerable population groups, pregnant mothers and children under1 year; used for annual planning purposes (2119 or 83 % of UHE-ps updated basic population profile). . Individual work plans developed according to planning template (Annually, quarterly & monthly)

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. HCs have assigned UHE-p focal persons and prepared referral feedback, action plans, and reporting formats. (81.1% of Health Centers have assigned). . Most of the direct services have been provided by UHE-ps at the Household level (postnatal care services, assessment of EPI defaulters, TB suspect identification, and antenatal care follow up, etc.). (2299 or 90.4 % provides postnatal care, 2299 or 90.4 % provides TB suspect identification etc.). . There are improvements in office level (kebele or Health Centers) documentation and recording; all the necessary recordings and registers are up-to-date. (2086 or 81.7% of UHE-ps ).. . UHE-ps use daily service recording tool during each household visit. (2086 or 81.7% of UHE-ps). . Family Health Cards available and being used. (1506 or 59%). . Households are aware of the services provided by UHE-ps, including postnatal care services, health education, short-acting family planning services, HIV testing and counseling services, nutritional screening, etc. . Good coordination with beautification of office sanitation campaign and provision for family planning services for hard-to-reach populations. . Households constructed proper liquid and solid waste management facilities in their compound. (991 or 38.8%). . Improvements in utilization of IEC/BCC or job aids while providing health education during house to house visits by UHE-ps .

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

During this reporting period, SEUHP regional teams organized review meetings to follow up on the implementation status of the action plans that were developed during the town level institutionalization workshops. One-day long review meeting workshops were conducted in all 13 towns in Amhara region, in eight SEUHP supported towns in SNNPR; in 11 out of 15 towns in Oromia region; five towns in Tigray region; and five sub cities in Addis Ababa. Dire Dawa and Harar have planned to do the review meetings during the next reporting period. The main objectives of the review meetings were to assess the implementation status of the action plans developed during the first round of workshops and to discuss on EFY 2011 priorities of urban health in respective towns and to include those priories into 2011 EFY plan. To standardize the workshop approaches, a workshop guideline and initial presentation slides were shared with all of the regions. SEUHP provided technical and financial support to each of the towns.

A total of 908 (447 female) participants attended the second round town level workshops (review meetings) that took place in Addis Ababa, Tigray, Oromia, Amhara, and SNNPR. The review meetings for Harar and Dire Dawa will take place during the first quarter of FY19. Participants of the review meetings include medical directors of health centers, UHEP supervisors, and UHEP focal persons, and representatives of City/Town Health Offices, Health Promotion and Disease Prevention Core Process leaders, WASH officers, and representatives from RHBs, town Greenery and Beautification Departments, Women and Child Affairs Office, Social Affairs, Education Office, Food Security and Job Creation Office, Youth and Sport office, and others. The second round town level workshop is kind of review meeting aimed at monitoring the progresses made on the Action Plans developed during the first round two days town level institutionalization workshop.

The activities performed in each SEUHP supported region follows:

The SNNPR SEUHP team provided technical support to the towns to conduct quarterly UHEP progress review meetings. The review meetings aimed to review the town’s previous quarter UHEP performance, to discuss findings of SEUHP-supported supportive supervision, and to review the implementation status of the revised UHEP implementation manual. The review meetings focused on the following challenges: lack of sectoral

SEUHP FY 18 Annual Report 52 convergences; poor progress of community based health insurance coverage; lack of internal integration between the UHEP activities and the health center/town health offices level activities; low quality of technical support being given to UHE-ps; poor compassionate, respectful and caring service in health centers; low coverage of long acting family planning services; and weak referral linkage and occasionally absence of poor ambulance services. Recommendations were made to address the above listed prevailing challenges, and to incorporate these recommendations into their quarter plans.

In line with the institutionalization process of the program, the Oromia SEUHP team communicated with the town health offices to budget for some of the town level activities including quarterly review meetings during EFY 2010. The town health offices organized quarterly review meetings using their own budget. Unlike the previous routine program review meetings, this round of the review meeting considered the involvements of other relevant sectors including: Greenery and Beautification Office of the Municipalities, Women and Child Affairs Office, Social Affair, Education Office, Food Security and Job Creation Office, Youth and Sport Office. The major discussion items during the review meetings included: strengthening collaboration among sector offices; improving the performance of referrals and complete referrals; model family training and graduation; data quality (including use of information for decision-making); enhancing support from kebele administration Health Centers or City/Town Health Offices s to UHE-ps; strengthening the Women Development Army; and strengthening PHCU support and Town Health Office involvement through supportive supervision, among others. The major achievements registered included: UHEP focal persons are formally assigned as deputy PHCU director in Health Centers; Health Centers started addressing the existing UHE-ps supply-chain problem, and channels of communication for issues related to supply items; the towns’ administrations demonstrated their commitment of addressing the existing challenges related to the duty stations of UHE-ps and supply-chain related issues; and the Health Center’s staff have been formally assigned to support UHE-ps.

The review meeting participants identified the following issues that need immediate action: implementing categorization approach of households and provision of targeted services as per the UHEP implementation manual; implementing activities that improve the linkage between UHEP and facility level services; implementation of UHEP at schools and youth centers; working with key stakeholders to address the urban WASH issues; program monitoring activities such as supportive supervision and review meeting; allocating budget for printing of current services data recording tools and using these tools until further direction is given from FMOH and RHB in relation to Urban Community Health Information System; and ensuring availability of basic supplies required to implement UHEP.

In Amhara region, bi-annual review meetings were conducted in different towns. SEUHP provided technical support to facilitate the review meetings. Following the ISS conducted in the region, the Regional Health Bureau organized a bi-annual review meeting involving woreda health offices, hospitals, health science colleges, and zonal health departments. Supply issues, HIV prevention, care and support, defaulter rate, and linkages were given significant proportion of discussion during the meeting. Recommendations were made on maintaining the standard of UHE-ps to households ratio, designing motivation packages to UHE-ps (optimization including career), moving UHE-ps office from the kebele to Health Center level, and the need for close support by Health Center staff to UHE-ps.

In Harar, monthly review meetings were conducted in all six urban woredas in collaboration with the Harar SEUHP team and Regional Health Bureau Health Promotion and Disease Prevention Department. Participants in the review meeting included UHE-ps, UHE-ps supervisors, heads of Health Centers, Regional Health Bureau department heads, referral focal person, woreda health office experts, woreda administration office and others sectors. In addition, SEUHP participated during the regional annual review meeting organized by Harari Regional Health Bureau from September 24 - 26, 2018. During that annual review meeting, the activities of the Urban Health Extension Program and the associated challenges were raised and discussed. Similarly, the Dire Dawa

SEUHP FY 18 Annual Report 53 regional SEUHP team provided technical support on the three-day UHEP biannual review meeting of the city administration. Ten UHEP supervisors presented the work of their respective UHE-ps displaying plans versus achievements for the period.

3.1.9 Provide comprehensive support to the second National Urban Health Conference

Based on the commitments of the first national urban health conference that took place in 2017, the second National Urban Health Conference (UHC) was held with a theme of Universal Access to Primary Health Care Services to all urban residents alongside the HEP Optimization Conference. As part of the preparation for the conference, SEUHP provided technical support in identifying themes for the conference, concept note development, setting the agenda, identifying and inviting key participants, and other related activities. At national level, SEUHP is represented in the Conference Steering Committee and other sub-committees like the Technical Committee, Communication and Documentation Committee, and the Exhibition Committee. The UHC took place on the first day of the three-day workshop held May 15-17, 2018 in Addis Ababa. The main objective of the UHC was to provide a platform to share lessons and experiences to advocate for attention to policies and programs to improve the implementation of the UHEP.

About 300 people representing different government sectors and NGOs participated in the conference that was mainly financed by MOH with cost share from SEUHP.

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Box I1: Major takeaways from the 2nd national urban health conference

 Better engagement of private sector can contribute to addressing urban health challenges: How to engage them better and how to deal with issues of accountability, regulation, sustainability, supervision and monitoring system, supervision perspective was discussed.  Attention and priority for urban health: leaders at all levels are responsible to advocate, promote and support the urban health programs for better results to be achieved. Just like the woreda transformation that is being implemented in rural woredas, urban cities need a customized approach for their health agenda.  Mainstreaming health in every urban development activity is also very important. Our policies, strategies and regulations should be customized for urban city contexts.  Inter-sectoral collaboration can be effectively executed by the lower level leaders and the community. Similarly, FMOH should keep working with parallel ministries on higher level strategies and decisions.  Mainstream health in all systems and structures of the government- FMOH should advocate for inclusion of health in all policies in the country. Advocacy to allocate appropriate budget for health in all structures and levels is also important.  School health is one of the main components of the HEP. FMOH and Ministry of Education will keep working in collaboration to ensure better school health system is in place.  HEP optimization to address major challenges in UHEP- Recommendations/directions stated in HEP optimization documents is promising; its execution needs strong support and follow-up at all levels.  Commitment and integration is very important for the PHCU redefining exercise. The other important thing on the program is the monitoring and evaluation practice at each level.  Health development armies (HDA) are the backbone for UHE-ps. Though there are a lot of challenges and gaps on it, it still supports the UHE-ps as well as the FHT significantly. Better engagement approaches need to be identified and implemented.  Commitment to the Community Based Health Insurance (CBHI) will be an important pillar in our system. The PHCU redefining exercise is a young initiative which should be implemented in line with CBHI. In order to envision a better and strong health system, strong leadership must be employed at all levels.

3.1.11 Facilitate structured learning and experience sharing visits

One of SEUHP’s achievements in FY18 was a structured learning and experience sharing visit to Thailand October 30-November 4, 2017. The visit was jointly supported by SEUHP and the Harvard T.H. Chan School of Public Health Fenot Project, funded by the Bill & Melinda Gates Foundation. The purpose of the learning trip was three-fold: 1) to orient participants on how Thailand has developed its national health financing and delivery systems over time to achieve Universal Health Coverage; 2) to expose participants to some of the key reforms to the Thai primary health care system; and 3) to introduce participants to the structures that Thailand has established for integrating health research and evidence-generation into the policy-making process, through visiting a number of health policy and research institutes.

Thailand was chosen for the learning trip because it is a middle-income country that has successfully addressed many of the challenges currently facing Ethiopia’s health care system, through more than three decades of health

SEUHP FY 18 Annual Report 55 system improvement. It was a promising learning opportunity as Ethiopia considers significant future strategies for health system development, as Thailand has invested in robust structures for evidence-to-policy translation and has achieved dramatic improvements in coverage, financial protection, and equity of primary health care services, resulting in improved health outcomes.

Fourteen delegates from the FMOH, Ethiopian Public Health Institute, and RHBs, led by Dr. Meseret Zelalem, director-general of the Office of the Minister, spent the week visiting institutes and health facilities within the Thai Ministry of Public Health (MOPH) to learn how the country developed its national health financing and delivery systems to achieve universal health coverage. Delegates visited the National Health Security Office (NHSO) to learn about the history of Thailand’s journey to universal health coverage and an overview of the three health insurance schemes: Universal Coverage (UC), which reaches the largest share of Thailand’s populations, and the Civil Servant, and Social Health Insurance schemes, which target specific employed populations, and the National Health Commission Office (NHCO) to learn about the various independent but interconnected institutes and tools that generate knowledge and collect citizen feedback in order to shape policies, including the Health Systems Research Institute (HRSI), the International Health Policy Program (IHPP), and the National Health Assembly, among many others.

The Thai Ministry of Public Health representatives continually referred to the concept of the “triangle that moves the mountain,” an approach used to solve complex problems by leveraging research, community input, and political involvement. Thai health advocates used this approach to move towards Universal Health Coverage.

Selected takeaways from the learning trip: . Thailand’s accomplishments in universal health are the result of several decades of progress and work, not just in health but also in economic and social sectors. Thailand’s experience enables today’s lower income countries to envisage a real and attainable pathway to Universal Health Coverage. . Thailand’s three schemes have achieved 100% coverage but are very different from each other in terms of management, financing, and benefits. . Thailand has focused its health center level facilities on prevention and outreach. Clinical services are provided in first-level hospitals and a strong linkage with Community Health Workers increases care for the home-bound elderly. . The Thai health center staffing is not so different from the UHEP. There is also potential in Ethiopia to use a team-based approach and to determine who and how many a health center serves based on a population census. . Champions can move health agendas forward. In Ethiopia, champions should be fostered at all levels, including community champions, to model commitment to system improvement. . The Thai National Health Council links experts and citizens to discuss needs and priorities and to solve differences through the National Health Assembly and other mechanisms. . The continued use of Community Health Workers engages rural youth and provides important home- based, chronic care support. . Separate and autonomous organizations encourage objective research and allows for a multiplicity of approaches; however, strong health system governance is needed to manage them. Researchers should consider the demand for evidence. Not all program improvement requires policy. The delegates are expected to share the knowledge gained on the trip with senior management at the FMOH and subsequently develop implementation plans to apply the lessons learned in Thailand to the Ethiopian context. Ethiopia will have to find its own path but lessons from Thailand can help inform that path.

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In an effort to facilitate translation of lessons to Ethiopia, discussions are going-on within FMOH and an action plan is prepared.

Sub IR 3.2: Improved Urban Health Data Collection, Analysis, and Utilization

3.2.1 Support FMOH, Regional Health Bureaus, and City/Town Health Offices to further strengthen the implementation of the data management system of the UHEP

Urban Health Extension Program (UHEP) service data recording tools (SDRTs) including service data recording format, HIV testing and counseling register, report compilation format and referral slip, etc. have been standardized in collaboration with the RHBs and copies have been distributed to all SEUHP-targeted City/Town Health Offices. As a result, UHE-ps are able to record services delivered at the household level on a daily basis. While waiting for the full-scale implementation of the Urban Community Health Information System (UCHIS) which is being pilot-tested. In FY18, SEUHP continued to support the implementation of the data management and use at City/Town Health Office level (i.e., collection, collation, analysis, reporting, and use) through regular SS and on-site coaching.

In FY18, SEUHP continued providing technical support on data management and use at the HC level through regular supportive supervision and onsite coaching. UHE-ps received follow up visits on their service data recording, reporting and documentation. About 3209 copies of service data recording tools were also distributed to UHE-ps to UHE-ps in all SEUHP supported regions. Each Service Data Recording Tool captures service data for more than 1,700 individual cases. UHE-ps received follow-up visits on their service data recording, reporting, and documentation. The town level UHEP strengthening workshops also helped participants from Health Centers and City/Town Health Offices better understand the UHEP data management system including available recording and reporting tools. This will boost the support given from Health Centers to UHE-ps and thus improve data management and quality improvement.

3.2.2 Support implementation of urban community health information system in SEUHP target cities/towns

A major persisting gap in the UHEP implementation is the lack of a standardized national health information system to monitor the performance of health services delivered to the community by UHE-ps. To fill this gap, the FMOH has initiated the development of a standardized and harmonized system in line with the revised health management information system (HMIS) indicators. SEUHP has been contributing to the development process of operational guidelines, user manuals, and Community Health Information System tools. SEUHP has also supported the pilot-testing through printing and distribution of tools and community folders and cascading of training to UHE-ps and their supervisors in SEUHP supported towns/cities The tools were finalized and have been pilot-tested in three SEUHP-supported regions (Addis Ababa, Oromia, and SNNPR) since July 2017.

In FY18, SEUHP continued providing technical as well as logistical/financial support to the roll out of the Urban Community Health Information System including assigning vehicles for experts from the FMOH to conduct site visits to the pilot sites. Currently, UHE-ps are providing home-to-home services at Hawassa (Gebeya Dar and Leku kebeles), Bishoftu (two Kebeles), and Addis Ababa (Alem Bank HC, Simegn kebede HC and Entoto No.2 Health Center) by fully applying the Urban Community Health Information System tools (community files/folders, service cards, tally sheets, HE registration, field registration, and reporting forms) and approaches. Since the beginning of the pilot implementation a total of 17,347 individuals (at Bishoftu, Hawassa, and AA) were visited and reached with different services. About 4096 of them were reached during the fourth quarter. The services

SEUHP FY 18 Annual Report 57 provided include family planning, EPI, antenatal care and postnatal care, hypertension screening, breast cancer screening, malnutrition screening, cervical cancer screening, breast cancer screening, and client referrals among others.

During the first half of FY18, a rapid assessment of the Urban Community Health Information System pilot implementation was conducted under the leadership of FMOH. Experts from FMOH, advisors from SEUHP central and regional offices, Regional Health Bureau Health Management Information System officers, City/Town Health Offices representatives, and Health Center medical directors were part of the Community Health Information System pilot implementation assessment exercise. During the assessment, the team noticed that community folders and other necessary tools are availed in each site, baseline data collected, HHs were categorized by blocks, and services are being provided. The introduction or implementation of UCHIS helped UHE-ps: to easily capture, analyze and interpret the community health information collected on the daily basis; to standardize monthly, quarterly and annual reports (using the CHIS reporting tool) with structured data sources; to identify community health service gaps and prioritize household service needs; to have community level health service documentation system across UHE-ps; and to have high quality data which was observed during data quality assessment.

Some of challenges observed during the assessment and routine supportive supervision visits include:

. UHE-ps to HHs ratio is not as per the standard which impacted UHE-ps’ efforts to provide services as per the UHE-ps guidelines and to clearly prioritize households based on their service needs. . Slow adaptation and utilization of service cards and other CHIS registration tools like field registrations, tally sheets and health education registration formats. . Absence of uniquely assigned house numbers forced UHE-ps to provide temporary numbering using a different system to differentiate it from that of the municipality. . Household categorization is difficult since there is no specific standard for the economic criteria and this forced the UHE-ps to categorize the HHs subjectively by evaluating the relative economic status of the HHs in their community. . There is difficulty in identifying specific community folders from the shelf and then family health profile registers because of an absence of labeling. . There are columns on the community folder as well as the individual cards/registers that are not clear to the UHE-ps, missing of some categories, and a narrowing of spaces were observed (e.g., Individual ID). . There are ambiguous categories that are confusing as per existing standards like the MUAC in the maternal and child health register versus HMIS standards, the cardiovascular disease screening form (non- communicable disease register for CVD, blood pressure measures do not show normal ranges). . Child health card does not capture EPI services for those who received services after 45 days of age after delivery. . There are no mechanisms to indicate follow up marks for services that need appointments (family planning, EPI, antenatal care, etc.) which could help UHE-ps to retrieve cases that have appointments easily. . No mechanism to capture monthly WASH related services other than the quarter service tally format . There was no lot quality assurance system in any recording or reporting form that should be incorporated with CHIS reporting form. . Poor follow up and support from City/Town Health Offices and Health Centers was observed.

Based on these and other specific findings indicated in the assessment report, recommendations were forwarded by the assessment team. SEUHP prepared a comprehensive slide presentation on the lessons learned (findings) of the pilot implementation and submitted it to the PP and M&E Directorate/FMOH to be presented for high level

SEUHP FY 18 Annual Report 58 officials so they would decide on the way forward. Based on this, the FMOH decided to scale up UCHIS to seven towns/cities in seven five regions (Bishoftu-Oromia, Hawassa-SNNPR, Harar-Harari, and Wukro-Tigray) and two city administrations (Addis Ababa and Dire Dawa).

As part of the scale up process, SEUHP in collaboration with FMOH organized a four-day CHIS tools finalization workshop in Adama town following the assessments made on the pilot-implementations. A total of 21 (F=8) individuals including experts from the FMOH, RHBs, sub-cities of City/Town Health Offices, and selected UHE-ps and Health Center staff from SNNPR, Oromia, and Addis Ababa participated in the workshop. In October 2018, SEUHP in collaboration with FMOH will organize national level training of trainers with the aim of implementing the cascading of CHIS training at regions before the end of 2018.

3.2.3: Facilitate evidence generation and dissemination on urban health

Since 2014, SEUHP has been contributing to the strengthening of Ethiopia’s urban health program. A large amount of data has been collected through the routine program reporting system, formative assessments, and surveys. In FY18, SEUHP planned to disseminate project results through peer-reviewed journals, blogs, and print or electronic media. In this reporting period, SEUHP organized a two-day of Strategic Information (SI) action plan development and a two-day manuscript writing workshop. Annex-2 shows the final list of stories (including program briefs, original articles, commentaries, case studies, and field action reports) to be produced through December 2018.

Some of the papers produced or published so far include the following:

. Urban community health information system initiative: lessons learned from pilot implementation; FMOH; Special Bulletin, 20TH Annual Review Meeting 2018, ARM 20 October 2018 (Published). . Ethiopia’s urban primary health care reform: Practices, lessons, and the way forward, EJHD, V. 32 (1), 2018 (Published). . Standardization and implementation of competency based in service training for urban health extension professionals: case study; FMOH; Special Bulletin, 20TH Annual Review Meeting 2018, ARM 20 October 2018 (Published).

Besides, SEUHP has submitted six abstracts (accepted-three for oral and three for poster presentations), one pre-conference workshop that deals with critical insights into what works for multi-sectoral governance and participation in urban health based on SEUHP’s experience, and one pre-formed panel that will be presented at the 2018 American Public Health Association and the 2018 15th International Conference on Urban Health that will take place from Nov. 26-30, 2018. Five people from SEUHP, the PHC and HEP directorate Director, and the M&E and Plan and Policy Directorate Director from FMOH will attend the conference as presenters, moderators and conference organizers. The topics of the presentations focus on UCHIS, PHCR, LMG, Quality of UHEP services, Malnutrition, antenatal care, and priorities for urban health in general.

3.2.4 Work with - School of Public Health and selected urban 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, AAU/SPH submitted the final technical reports of two studies after accommodating the feedback from SEUHP: 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’

SEUHP FY 18 Annual Report 59 adherence and competency in line with the revised UHEP implementation manual. A one-day dissemination workshop will be organized in the next reporting period. The principal investigators of the two studies made a presentation at the US-Embassy (journal club) to USAID staff members. In this reporting period, the researchers at AAU/SPH, in collaboration with staff members of SEUHP have submitted a manuscript for peer-reviewed journal publication which is expected to be published in April 2018.

The Centre for Urban Health Development at AAU/SPH had an Exhibition corner on the 29th EPHA Annual Conference (February 26-28, 2018), ECA, Addis Ababa. Newsletter, research findings with policy briefs, and leaflets were used to promote the Centre. The exhibition has been visited by over 350 people. Key lessons learned from the conference include that such conferences provide a chance to advocate urban health initiative and to collect constructive inputs from the participants. The conference was an opportunity to meet concerned individuals who are interested to participate on urban health and urban health related activities.

The Center for Urban Health Development-Ethiopia was established with the support from SEUHP is currently serving as a center of partnership and policy-program debate on urban health and hosts an inter-disciplinary database on urban health. The goal of the center is to be the university’s research hub focusing on key urban health priorities of the country and host of the think-tank groups. The center aims to provide information, research, and partnership opportunities for AAU, connecting the university, practitioners and policy makers to both national and global platforms. A consultative meeting was held at Bishoftu town (June 8-9, 2018) with the aim of discussing the draft strategic plan for the Centre for Urban Health Development-Ethiopia. Issues addressed and discussed during the workshop include reviewing progress, lessons and the way forward, and the vision, mission, and goal of the center. Concept notes were developed to solicit further support for the center. During the workshop, the sustainability of the center, areas of focus for the coming years, and potential donors for the respective concept notes developed were discussed. As part of this effort, the Health Science College/SPH developed a thematic research proposal and submitted it to the AAU Academic Research Vice President Office for funding. This will help in ensuring the continuity of the Center for Urban Health Development.

The following activities were implemented to strengthen the urban health development center:

. Urban health related research articles have been collected from institutions working on urban health and downloaded from different online journals and made available in soft and hard copies at the center. . Urban health advocacy and promotional materials were developed and distributed on different forums and professional association conferences. . Urban Health Related Data collected from different institutions who are working on Urban Health. For instance, all EDHS raw data (2000, 2005, 2011, 2014, and 2016) was collected from CSA and made available at the center for the academia who want to do research using secondary data. . Concept notes have been developed to solicit further support to the center.

A visit by media professionals in Addis Ababa City organized by the CUHD-E’s/AAU revealed evidence of compromised health and wellbeing among slum residents. Motivated by reports from media professionals and considering the scope of the urban health challenges, CUHD-E produced a documentary film entitled “State of Urban Health in Ethiopia: The case of Addis Ababa” using the resources of AAU. The film was also aired on Addis TV. The main objective of this documentary film was to document evidence related to urban health, including slum areas of the city, and to screen it through public media to generate policy attention.

The Center for Urban Health Development-Ethiopia also organized a half-day seminar at the School of Public Health Lecture Hall, Zewditu campus, on June 29, 2018. The seminar covered the main research findings of the

SEUHP FY 18 Annual Report 60 two studies conducted in FY17: “Assessing vulnerability to health and health related problems: Places and people in urban centers of Ethiopia” and the “Health Services Quality Assessment in Urban Health Extension Program.” Lecturers from the School of Public Health, students in the public health graduate program, and others from the AAU health science college participated in the seminar. AAU’s subcontract with SEUHP has also ended in August 2018.

Sub-IR 3.3: Strengthened Organizational Capacity of Partner to Perform Core Functions of UHEP

SEUHP has been working with the Emmanuel Development Association (EDA) to build on existing infrastructure and improve the ability to mobilize, design, implement, and monitor UHEP. In previous fiscal years, SEUHP has been providing capacity building support to EDA after many major capacity gaps were identified. Based on the findings, building capacity on Human Resource and M&E were prioritized. In this reporting period, through series of regular technical and administrative meetings, EDA received the necessary support from JSI/SEUHP. The support included addressing skills and knowledge gaps through coaching. Technical support was also provided to develop EDA’s FY18 work plan. EDA concluded its partnership agreement on June 30, 2018.

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IR-4 IMPROVE SECTORALCONVERGENCE FOR URBAN SANITATION AND WASTE MANAGEMENT

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Sub IR 4.1: Increase WASH Governance and Management Capacity at All Levels

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 supplies, sanitation and hygiene facilities and services, and promoting good hygienic practices. Improving the quality of sanitation and hygiene services is one of the priorities of the country’s five-year Health Sector Transformation Plan (HSTP). SEUHP’s work on WASH is also linked to USAID’s Water and Development Strategy (2013-2018) “Water for Health,” and its specific goal is to “Improve the health outcomes through improved access to sustainable WASH.”

4.1.1 Implementation of integrated urban sanitation and hygiene strategy

A memorandum of understanding (MoU) was signed to implement Integrated Urban Sanitation and Hygiene Strategy (IUSHS) during the first national urban health conference that was conducted in 2017. The signatory Ministries were Health, Water, Irrigation and Electricity, Urban Development and Housing, Finance and Economic Cooperation, Education, Forest, Environment and Climate Change (MoFECC), and Culture and Tourism. After the endorsement of the strategy, SEUHP continued its support to FMOH and RHBs in customizing and cascading the strategy at different levels.

In this reporting period, the national TWG held three meetings. As a member of the TWG, SEUHP gave technical support in the development of the TOR for the implementation of the strategy at different levels. At the regional level, SEUHP technically supported the printing and distribution (Amhara and Tigray) of the National Hygiene and Environmental Health Strategy, IUSHS, implementation guide, strategic action plan, and MoU documents.

SEUHP in collaboration with the respective RHBs organized workshops for 31 participants in Amhara, for 112 participants in Dire Dawa, for 55 participants in Harari, and for 11 participants in SNNPR to endorse the strategy, its implementation guide, and strategic action plan. During the workshops, regional level MoUs were signed and regional Steering Committees and TWGs were established. In Amhara Region, the signed MoU was customized and shared to zonal and city/town administrations with an official cover letter signed by the RHB (the chair of the steering committee) for its cascading to lower levels. In Oromia, the customized regional IUSHS documents (IUSHS, implementation guideline, action plan and MoU) were shared for different sector bureaus for their review. However, the sectors have not yet endorsed the documents due to other competing priorities.

4.1.2 Support to sustain and institutionalize the already established WASH forums in selected 13 cities/towns

In previous fiscal years, SEUHP has been providing technical and logistics support in the establishment and strengthening of WASH platforms in SEUHP-supported cities/towns in Addis Ababa, Amhara, Dire Dawa, Harar, Tigray, SNNP, and Oromia regions to improve multi-sectoral coordination for sanitation and waste management services. To strengthen the efforts that have been made by SEUHP and to ensure the functionality of the established WASH platforms, in FY18, SEUHP continued its technical and logistic support in

 Developing WASH platform review meeting guide with proposed agendas and post meeting reporting templates that will be used to facilitate regular platform review meetings;  Organizing city/town level WASH review and planning meetings in 13 cities/ towns (Amhara= 3, SNNPR = 3, Oromiya = 3, Tigray = 2, Addis Ababa, and Harar;  Revising and standardizing urban WASH platform TWG members’ capacity building training material and provided training to TWG members; and

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 organizing town level institutionalization workshops with Mayors in 13 towns to institutionalize and sustain the activities of WASH plat form TWGs.

Following these efforts, the SEUHP regional teams in collaboration with their respective city/town health offices conducted the following activities in fourteen cities/towns.

Table 11: Activities performed by town level WASH platforms, October 2017-September 2018

City/town Activities carried out in the reporting period

Debre Markos . Conducted three regular meetings and reviewed the integrated work plan and its implementation. . Following the first national urban health conference held in Addis Ababa, the WASH steering committee at Debre Markos organized a town level urban sanitation and hygiene workshop by engaging higher government officials, community representatives, Debere Markos University officials, religious leaders, and other influential individuals. . During the workshop it was decided that the technical working group will conduct sanitation campaigns every two weeks regularly. . With technical and logistics support from SEUHP, the steering committee and technical working group conducted experience sharing visit at Bahir Dar. Following the visit, the technical working group organized six new private associations for solid waste collection and decided to collect 15 birr, 300 birr and 5000 birr service fees monthly per household, institution, and Debre Markos University respectively together with water bill. Woldia . Regular monthly town level environmental sanitation campaigns organized. . Discussions held with school directors in five schools and school level sanitation campaigns conducted. . 20 temporary solid waste collection containers purchased by town administration and put in selected sites in the town. . Steering committee conducted supportive supervision on hygiene and environmental health components of health extension packages at household level. . The municipality started implementing the solid waste collection services fee collection system with the water bill system starting from December2017. . Implemented regulatory measures in 26 foods and drinking establishments and penalized those who disposed their waste illegally. . Established one new additional solid waste collector association and strengthened three existing associations through capacity building trainings. . Inspected and disposed of expired bottled soft drinks. . Conducted monthly water quality testing.

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Finote Selam . Work plan was developed by the technical working group and was approved by the steering committee and budgeted. A total of 800,000 birr allocated to buy waste collection and transportation vehicles, 50,000 birr to buy road side dustbins, 20,000 birr to maintain public latrine, 4,000,000 birr for construction of final solid waste disposal site and 500,000 birr to construct slaughterhouse construction). . Two trucks were purchased and are providing solid waste collection and transportation services in the town. . Three solid waste collector associations were organized in addition to the existing three associations and 38 members of the association received training. . Solid waste collection service fees are linked with water bill payments. . 6,000 leaflets were developed and distributed to the community and Health Development Armies to increase awareness on waste management. . A sanitation campaign was conducted in government office, schools, health institutions and communities. . Inspected the waste management systems of schools, health institutions, food and drinking establishments, shops, and religious institutions. . Conducted monthly water quality testing. . Selected and prepared final waste disposal sites. Gonder . Town health office purchased plastic containers and distributed them to all sub cities to handle non-sharp infectious waste appropriately in all UHE-ps offices. . Conducted daily support to 12 solid waste collect associations to ensure proper solid waste management by the SMEs. . Inspected 115 institutions including 2 abattoirs to check how they are disposing of waste and provided real-time feedback. . 22 Hotel workers had medical checkup and certified to work on food services. . Technical support was provided to all established school health clubs. . Noise pollution supervision conducted on 12 noise producers like music shops and got regulatory actions. . Conducted regular monthly water quality testing. Debre Tabor . The technical working group conducted solid waste management performance review meeting. There were 300 participants selected from community members, solid waste collector association members, Kebele leaders and other stakeholders. . Conducted monthly water quality testing. . Selected and prepared final waste disposal sites. . Conducted two environmental impact assessments on projects implemented in the town. . To link solid waste collection fee with water bill, the team did assessment of households to check availability of water gages, and then set tariffs and prepared regulations for implementation. . Conducted regular support and inspection to solid waste collectors on solid waste collection and management systems. Bahir Dar . 272 influential persons were selected and oriented on general environmental hygiene in Bahir Dar, in addition to the 150 individuals mentioned in the report. . There was an illegal waste disposal site in Tana sub-city covering an area of more than one hectare. As a result of the establishment of the WASH LMG team, budget was allocated and the trees which shaded the solid waste were cleared. A large volume of solid waste was transported to the city’s final waste disposal site. The leftover waste was buried and covered by soil. The environment was cleaned using machines. Currently, the land has officially been transferred to organized self-help community groups to be transformed into a recreation center.

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Addis Ababa . The city level technical working group conducted its regular meetings and discussed on major problems and challenges related to solid and liquid waste management, public latrine management and other WASH related issues. . WASH platform workshop was conducted for Kolfe Keranio Sub City. A total of 18 participants from different WASH related sectors attended the workshop. Dire Dawa . The technical committee held two meetings in the reporting period . The technical working group organized sanitation campaign and SEUHP supported city administration by proving materials such as shovels, pick axels, gloves and brooms for the campaign Jimma . Conducted town level sanitation campaigns by mobilizing the community, investors, influential people, higher officials of the town, the sanitation ambassador of the town (Jimma Abba Jifar football Club) and religious leaders. . Organized a one-day sensitization workshop under the motto of “We demand Clean and Safe environment.” Shashemene . ReviewEnvironment meet ingsfor Jimmaconducted town”. to Arevitalize total of the250 WASH people platformattended as the most workshop of the headschaired of bysector the Mayor offices areand newlyJimma assignedUniversity as President.part of the government’s reform process. A total of 17 participants attended the meeting. The MoU was endorsed by the newly assigned Cabinet. Bishoftu . Town-level workshop organized to sign the MOU and to endorse an integrated action plan prepared by the TWG. A total of 13 participants (females=2) attended the workshop. . A total of 32 solid waste road side dustbins purchased by the municipality and placed in different part of the town. Nekemte . The technical working group conducted inspection of food and drinking establishments in the town. . Proper collection and disposal of solid wastes and emptying of liquid waste pit services facilitated. . Awareness creation activities conducted for the community through community meetings, HAD structure, and students. . One day WASH platform strengthening workshop was conducted; 21 participants representing eight town level sectors and sub city managers attended the meeting Mekele . SEUHP in collaboration with town administration organized a one-day town level review meeting. A total of 28 Participants (F=11) selected from WASH sector offices attended the review meeting. . The technical working group conducted regular meetings every two weeks at city level chaired by the Mayor. . As per the recommendations of the TWG, the organizational structure of sanitation and beautification office was reviewed and restructured by adding two new case teams with additional 80 regulatory officials deployed. . The technical working group organized Town level experience sharing visit at Martha kebele which was selected as a model in the town. A total of 180 participants selected from seven kebeles attended the visit. . Three rounds of city level sanitation and hygiene campaigns conducted led by the Mayor with the participation of Mekele football club and Semien region military camp. A total of 131,556 people (97% females) participated in the sanitation campaign. . THO in collaboration with Ethiopian Orthodox Church Mekelle Diocese assessed 18 holy water sites, identified gaps and challenges, and proposed action points that was shared to Mekele water supply and sewerage office. Additionally, 36 hand washing facilities and 36 dustbins were procured and distributed in collaboration with partners. . Availably and utilization assessment of School WASH facilities was carried out in Mekelle city. Gaps were identified and then hand washing and dust bin procured and distributed to the schools. . Secured budget to construct 7-model public latrines, one per sub city, for 2011 EFY. . Developed integrated work plan and improve the performance of WASH platforms in each town.

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Alamata, . The technical working groups of the respective towns conducted regular meetings. Maichew, . Alamata town administration allocated 500,000.00 ETB for town level hygiene & sanitation activities Aksum, Shire and did maintenance to the town slaughtering house. and Adigrat . About 2-5 rounds of sanitation campaigns conducted in each of the five towns and a total of 92,381 people (65% females) participated during the campaign (Alamata=21,328, Maichew=7,839, Aksum=32,000, Shire=11,823, and Adigrat=19,391). . As per the recommendation of the TWGs in the respective towns, Alamata, Maichaew, and Aksum town administrations recruited & deployed street cleaners and waste collectors; Aksum town allocated budget for town level hygiene & sanitation and rehabilitated two non-functional public latrines. . To enhance and strengthen hygiene and sanitation interventions, Alamata, Maichew, and Adigrat towns have recruited & deployed a total of 40 sanitation regulatory individuals. . Developed integrated work plan and improve the performance of WASH platforms in each town. . Monthly sanitation campaigns carried out regularly with the involvement of head of the sector actors. . Community mobilization conducted to prevent AWD outbreak

Following the development of the customized WASH LMG training manuals based on the lessons learned from the facility level LMG training (see Section 3.1.2),

SEUHP implemented WASH LMG training in Amhara, Addis Ababa, Oromiya, SNNPR, Tigray and Harari regions with the aim of enhancing the performance of platform members. Participants of the training include: mayors and/or their representatives and heads of the offices of the Municipality, Health, Education, Finance and Economy, Community Participation, Greening and Beautification, Environmental Protection and Forest, Water and Sewerage, and other city/town WASH sectors. These training sessions were organized mainly to strengthen WASH platforms in terms of leadership, management and governance. On this regard, first round LMG training was conducted in six towns/sub cities (Jimma, Shashemene, Nefas Selik Lafto and Arada sub Cities, Harar, and Mekele) and second round training was conducted in 14 towns/sub cities; Akaki Kality sub city, Yeka sub city, Kolfe Keraneyo sub city, Nifas Silk Lafto sub City, Arada sub City, Bahir Dar, Debere Markos, Jimma, Adama, Bishoftu, Wolayta Sodo, Hawassa, Shashemene, and Hossana. A third round of LMG training was also organized in Bahir Dar, Debre Markos, Dessie, and Hossana towns. A total of 607 (first round), 632 (second round), and 152 (third round) WASH platform members attended the training.

The leadership training was particularly successful in three towns in Amhara region because of the commitment of the town administrators. Summary of the successes from the three towns is presented as follows. The details can be found in Annex 3.

• Model family graduation coverage increased – from 29% to 60% (Bahirdar, Tana sub-city). • Solid waste collection service delivery coverage increased – Bahirdar (85% to 90%). • Media engagement on urban WASH issues increased – Bahirdar, Amhara Mass media developed and aired three episodes of TV programs with different urban WASH issues. • Construction of improved latrines increased from 29% to 39% at Debere Markos town. • Water safety coverage increased from 72% to 77% at Debere Markos town. • Number of projects with EIA certificate increased in Debere Markos town (during the baseline assessment from 64 projects only 6 projects had EIA certification, but after the training 15 projects were certified for EIA certificate). • Number of organizations with proper liquid and solid waste management increased – Debere Markos town from 10 organizations, nine of them properly managed their solid and liquid waste. In Desse town during the baseline about 200 organizations released their wastewater to open ditch, after the training 85 organizations connect to their septic tank system.

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• Number of schools with WASH facilities increased: at Debere Markos town schools properly collects their solid waste increased from 0% to 58%. In Desse town the proportion of schools with proper hand washing facility increased from 6% to 34.5%.

Sub-IR 4.2: Increased Supply of Low-cost Sanitation and Hygiene Products, Facilities and Services

4.2.1. Create model WASH demonstration sites in selected cities/towns

Model demonstration sites play key roles in building the capacity of UHE-ps and Health Development Armies and their members to promote standard and quality services, products, and facilities in their respective working areas. This approach has shown promising results from previously established demonstration sites in schools and health centers like in Debere Markos town.

Building on this, in FY18, SEUHP planned to establish model demonstration sites in other SEUHP supported towns. Procurement and installation of different sanitation and hygiene technology options was conducted in Soddo Ligaba primary school WASH demonstration site. This helps UHE-ps to promote proper household water management, sanitation and hygiene practices and services through practical demonstrations in the school and at the community level. SEUHP in collaboration with the town health office provided orientation to the UHE-ps of the Kebele and their supervisor on how to use the WASH demonstration rooms to educate their clients.

4.2.2 Implement model kebele/ketena in selected cities/towns

Evidence-based promotional work is required to enhance urban sanitation and waste management service delivery. The absence of model sites that can be used for promotion purposes is one gap that should be addressed, documented, and shared.

In FY17, SEUHP in collaboration with Debere Birhan town administration and Emanuel Development Association (EDA) selected one village where both solid and liquid waste is indiscriminately disposed of. This site was cleaned through community mobilization and now it has become a model village. In FY18, a team composed of 31 people selected from the community, town administration, EDA and civic organizations such as Iddir continued to implement the activities identified during the stakeholders meeting. Additionally, all households that practiced open defecation due to a lack of latrine or substandard latrines in the model village were identified and supported by UHE-ps and Kebele administration to construct latrines and prepare hand washing facilities.

A team organized from zonal and town health offices evaluated Fana kebele of Sodo town in SNNPR and verified that it fulfilled all criteria to become a model kebele. Fana kebel was designated a model kebele on May 13, 2018. SEUHP provided technical and logistical support to the town administration and the town health office in conducting the baseline survey, engaging the community through a sanitation campaign, planting different seedlings to create a green space, and following up on the UHE-ps’ work.

4.2.3 Promote Public-Private Partnership (PPP) model on urban sanitation and waste management

Liquid and solid waste management service provision is one of the key areas for private sector investment. In Ethiopia, there are no policies and guidelines to promote the engagement of private sector on urban sanitation and waste management. This is mainly due to lack of financially viable models to attract involvement of the private

SEUHP FY 18 Annual Report 68 sector in sanitation and waste management service delivery.

In this reporting period, SEUHP conducted an assessment on the existing PPP. Based on the findings of the assessment, a PPP implementation guide was developed with proposed models and shared with stakeholders (Ministry of Urban Development and Housing and Ministry of Water, Irrigation and Electricity). In line with this, a public toilet management model is being tested in four newly constructed public toilets at Kemisse, Kombolcha, Sekota and Adigrat towns. The next plan is to document the lessons as part of SEUHP’s strategic information action plan and to share the findings to improve public latrine management.

The Amhara SEUHP team provided support to the town administrations of Debre Birhan, Dessie, Woldia, Gondar and Debre Markos in establishing WASH platforms through the following key activities; . Organizing capacity building trainings for WASH platform technical working group members. . Providing technical support for TWG members in developing and implementing integrated work plans. . Organizing review meetings to share key lessons from each sector representative in the platform. . Organizing experience sharing visits for the platform members.

As a result of this support, all SEUHP-supported towns in the region are working with organized small and mico- enterprises (SMEs) (private enterprises) for solid waste collection service delivery. Debre Birhan, Dessie, Woldia, Gondar, and Debre Markos towns organized additional small and micro-enterprises for solid waste collection because of the active follow up and support of the technical working group. Towns including Dessie, Gondar, Finote Selam, and Debre Markos linked the solid waste collection fee system with water bill system. Town administrations have provided capacity building trainings for small and micro-enterprise members in collaboration with the TWGs. All SME groups have signed MOUs with the local government on service delivery.

Similarly, the WASH platform TWG in Gondar town administration facilitated financial support from Gondar University and provided capacity building training for solid waste collectors and shared school WASH interventions for wider scale up. Solid waste collectors are now using personal protective equipment appropriately as the result of capacity building training. Sectors in Debre Markos are providing support to the private associations based on their roles and responsibilities: THO trained on occupational health and safety (OHS) in collaboration with Municipality), Micro and Small Scale Enterprise Office organized the associations; Water and Sewerage Office made the follow up of the incorporation of the monthly waste collection with water bill system, and the Mayor Office monitored the achievements and challenges every month. Debre Markos town Municipality had weekly environmental sanitation campaigns in each village in addition to a house-to-house solid waste collection system. A one-day discussion was held between associations and WASH sectors to identify gaps and plan to improve waste management system.

The Addis Ababa regional SEUHP team also provided support for the renovation of one poorly functioning public latrine with shower which was constructed by EDA at A/Kality sub-city. The purpose of the renovation was to implement the public toilet management model in Addis Ababa. The maintenance works included; repairing the damaged parts of the wall, the floor, the roof, and changing the doors for both the shower and latrine rooms, partitioning female rooms for better safety and privacy, installing a four thousand liter capacity water collection tanker with stand, and a hand washing facility. The renovated public shower and latrine gives service to an average of 150 individuals per day and serves as a regular source of income for 15 females working in the facility. SEUHP also facilitated a one-day business management and skill based orientation training for the group who are managing the public latrine to expand their business using different income generating activities in line with the public latrine and shower services.

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Sub IR 4.3: Increased Demand for High-quality Sanitation and Hygiene Products, Facilities, and Services

4.3.1 Conduct post Integrated Refresher Training (IRT) follow up to build the technical competency of UHE-ps

As part of its objective to enhance the technical excellence in service provision by improving the knowledge, skills, and attitude of UHE-ps in previous years, SEUHP developed competency-based training modules and cascaded capacity building training to UHE-ps, supervisors and city/town health office staff in SEUHP targeted cities/towns. SEUHP’s WASH training module was customized into the national Integrated Refresher Training (IRT) guideline including water, sanitation and hygiene module. In FY17, SEUHP organized Master training of trainer and regional training of trainer trainings in SEUHP supported cities/towns. In this reporting period, post- training WASH skill reinforcement follow-up visits were conducted in different towns. For further details, refer sections 1.1.1 and 1.1.2 of this document.

4.3.2 Engage media for the promotion of proper urban WASH services

Refer section 2.2.1 of this report.

4.3.3 Conduct mass awareness creation using local mass-media

Refer section 2.2.3 of this report.

4.3.4 Facilitate WASH Movement in three cities/towns

Refer section 2.1.2 of this report.

4.3.5 Strengthen Involvement of UHE-ps in school WASH Activities

In this reporting period, SEUHP supported UHE-ps’ school-based initiatives to establish or strengthen WASH clubs in four schools and to promote sanitation and hygiene through peer-to-peer behavior change activities. In Amhara region, UHE-ps at Nigus Teklehaymanot primary school at Debre Markos town provided technical support to school health and Red Cross clubs to raise awareness for their peers in the school on health and hygiene issues. The schools’ girls’ club arranged a mini-shop in the school that avails menstrual hygiene materials to students. The school mini-media of Tsadiku Yohannis primary school at Gonder also received support from UHE-ps. They have a regular schedule, two days per week, and facilitate peer to peer education on health issues including water, sanitation and hygiene.

Training was organized on hygiene and sanitation for education office members and school principals at Dessie town by EDA. Thirty trainees attended the training which addressed hand washing facilities, adequate and quality water supply, availability and use of latrines, room for female students’ menstrual hygiene, and the role of behavioral change communication on hygiene and sanitation for the school community and the generation at large. Similarly, UHE-ps trained school health club members on first aid at Ewuket Fana elementary school of Bahir Dar town. These club members provide peer to peer education through dramas, poems or reading formats and reaching school society using loudspeakers provided by SEUHP. Following the experience from Debre Markos School, they prepared menstrual hygiene room for girls..

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In Dire Dawa, the SEUHP team provided technical support for the RHB to celebrate global hand washing event with the theme of ‘Our Hands, Our Future’ at different schools. About 2,000 students, teachers and school administration staff participated and more than 2,500 WASH focused leaflets were distributed to the participants.

Sub IR 4.4: Increased Knowledge Base to Bring WASH Innovations to Scale

In an effort to strengthen the knowledge base for WASH innovations, SEUHP has identified, documented and shared the various lessons from its WASH activities implementation and passed the lessons to stakeholders (governmental and WASH implementing partners). Best practice articles from lessons on SEUHP’s construction of public WASH facilities and WASH LMG implementation were developed. The lessons were disseminated through the JSI website, the urban health newsletter, and presentations. In addition, the impact of SEUHP’s WASH activities on the lives of the beneficiaries are documented as success stories and disseminated through various platforms including on the national health annual review meeting that was held in October 2017 and at EPHA’s 2018 annual conference, in February 2018. SEUHP participated in a two-day multi-stakeholder forum organized by the Ministry of Water, Irrigation, and Electric attended by 350 people from all over the country. In this forum, SEUHP had an exhibition booth where SEUHP’s lessons including the PPP Model approach were displayed and publications were shared with participants.

The SEUHP SNNP regional team shared its experience during the two-day (June 28-29, 2018) regional WASH consultation and IUSHS familiarization workshop organized by the SNNP RHB. Sixty participants from 20 One WASH National Program (OWNP) implementing towns in the region attended the workshop (three participants per town: one each from the offices of the town administrator, health, and finance). During the workshop the RHB presented the main achievements of each town and discussed the regional IUSHS.

Sub IR 4.5: Implement Emergency WASH Facilities Construction

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The construction and/renovation of sanitation and hygiene facilities has been going on in five towns; Adigrat and Alemata (Tigray Region) and Sekota, Kombolcha and Kemessie towns (Amhara Region). The WASH facilities were constructed or renovated while taking gender and social inclusivity into consideration.

In this reporting period WASH facilities constructed at Kombolcha, Kemisse, Sekota, and Alamata towns were inaugurated in the presence of national, regional, zonal, and town level higher officials including Mayors and cabinet members. The inauguration at Kombolcha and Kemisse towns were done in the presence of his Excellency Dr. Kebede Worku, Sate Minister of FMOH and Dr. Abebaw Gebeyehu, Head of Amhara RHB. Constructions and/or renovations of different water, sanitation and hygiene facilities in Adigrat town were also finalized in this reporting period.

During the fourth quarter of FY18, a WASH facility visit was conducted by SEUHP’s Amhara regional team and central office staff members at Kombolcha & Kemssie towns. The team held discussion with small and mico- enterprise members, Mayor of Kemissie, deputy manager of Kemissie municipalities, Health office head, and Water and sewerage utility office managers. The team also conducted an exit interview with WASH facility users at both sites after receiving the services (shower and toilet). All the interviewees indicated that they are happy with the quality of the service they are getting and on the service fee. Additionally, observations of the facility were conducted with a checklist and both facilities were found to be in good condition and were very clean. However, shortages of water and road access to the toilet were major challenges at Kombolcha. The water bill tariff is very high at both sites because facilities are considered business institutions. To solve this problem, the team had discussion sessions with the respective sector offices and consensus was reached such as to consider the facilities as services provider institutions not as profit making business entities.

Details of each WASH facilities constructed in different towns are summarized as follows:

4.5.1 Construction of new latrines with shower facilities

The construction of a one block standardized water flushed public latrines with eight rooms (3 for males, 3 for females,1 for disabled males and1for disabled females) was completed in each of Kombolcha, Kemissie, Sekota, Alamata and Adigrat towns. The facilities have 4 shower rooms (2 for males and 2 for females) with urinals, hand washing facilities, solar power system and water storage with water capacity ranging from 5000-10,000 liters. The rooms for persons with disability include both shower and latrine seats. The facilities were handed over to the respective town administrations.

A group of unemployed people with 4-8 members are organized in each town including returnee refugees from Arab countries (Kombolcha), women living with HIV (Kemissie), Church students (Alamata), and youth/community members (Sekota and Adigrat) by the respective town administrations to manage the public latrines. SEUHP provided training to these groups based on the training packages indicated in the public toilet management model. SEUHP also prepared service users’ registration forms for shower and latrine users and orientations were provided for the SME/groups.

In Kemisse, SME members are managing the public latrine and shower facilities have been generating 1000 birr/month for each member. Members have already saved 13,000 birr in the group’s account. They have already paid a loan amount of 7,000 birr (seven thousand birr). Since February 2018, a total of 11,708 (F=2808) and 11,751 (F= 2441) people used the latrine and shower services respectively. At Kombolcha, with the aim of expanding the business, the SME group at Kombolcha town successfully obtained a 20,000 ETB loan from Amhara Credit and Saving Institution (ACSI), ten chairs and one tent from BGI Ethiopia Kombolcha branch, and 50

SEUHP FY 18 Annual Report 72 seedlings from Kombolcha town administration for greening. The group has constructed four huts for additional services. The facilities at Kombolcha town have so far served a total of 1619 (f=378) latrine service users and 5051 (f=369) shower service users.

The latrine and shower facility at Alamata town (Enda Eyesus Church) serves for about 728 church school students and other church community members. The facility is expected to alleviate the problems related to waterborne diseases which have been serious health problems for the students residing in the church compound. The students used to defect on the open field and they did not have hand washing and shower facilities. Following the training, participants developed action points and the following were achieved in the reporting period:

. The church community has scheduled weekly bathing days and assigned daily cleaners among students. . Alamata town health office has assigned experts and UHE-ps for regular follow up on the proper utilization of the facilities. . The church community has developed rules and regulations to ensure appropriate utilization of the facility and generate income to be used for its further maintenance and minor renovations. . The church community has so far collected 11,000.00 Birr from the religious school students to be used for maintaining the functionality of the facility.

In addition to the public latrines, a one-block new standardized water flushed latrine having one seat and one bathing room with hand washing facilities and reservoir with storage capacity of 1000 liter was completed and handed over to Sekota Health Center. About 25 pregnant and delivering mothers are expected to use the facility per day.

4.5.2 Renovation of communal latrines:

In this reporting period, renovations were made in three non-functional communal latrines at Kombolcha, Kemissie, and Sekota. The renovations included maintenance of damaged parts of walls, floors, roofs, and doors of the communal latrines, and installing of a 5,000 liter capacity water storage reservoir (in each town) and hand washing facilities. The renovated facilities were handed over to the respective town administrations in the presence of committees from the community. The renovated communal latrines gave service to 157 HHs (Kombolcha=57, Kemissie=60, Sekota=40) or about 785 individuals (Kombolcha=285, Kemissie=300, Sekota=200) since they were renovated.

4.5.3 Construction and installation of pipe line extensions, public water points, water reservoirs, and public shower

Pipeline extensions: Construction or installation of pipelines extensions from towns’ reservoirs to communities (including two public water points) were completed and handed over to the respective town Water and Sewerage Utility Offices of Kombolach, Kemissie, Sekota and Adigrat. The pipelines extension ranges from 1.1km at Adigrat to more than 2kms at Kemissie. At Kemissie, the WASH committee members received training and started saving money for the operation and management of the facility. In addition to the pipelines extension, water points were also constructed (one at Kombolcha and two for each of Sekota and Adigrat). The pipelines at Kemissie and Sekota are expected to serve about 300HHs (1500individuals) and 120 HHs (600 individuals) respectively.

Water reservoirs: In this reporting period, the installation of water reservoir tankers having a capacity of 5,000- 10,000 liters and the extension of water pipelines to selected rooms were also completed and handed over at

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Kebele 07 Health Center (Kombolcha), Kemissie Health Center, and Alamata Health Center. A hand washing facility was also constructed near the latrine at Alamata Health Center. The water reservoirs provide services for 20-50 people per day.

Hand-dug wells: In addition, three hand-dug wells were completed in Sekota town. Water quality tests were conducted and the result indicated the quality of water of the wells is safe for human consumption. The three hand-dug wells will benefit 220 households (1100 people). These water sources will improve the health of the local community who have been suffering from water shortages and related diseases. Three WASH committees of 21 members were selected in those three water supply schemes and the WASH committee members received 3 days of training. The training covered hygiene and sanitation, safe water handling systems; waterborne diseases, causes, consequences and prevention; and the roles and responsibilities of WASH committee including sustainability, water fees, and management and maintenance. Maintenance of eye of the spring, collection chamber, distribution faucet and cloth washing facilities was also completed and handed over to Kombolcha Water and Sewerage Utility office. The spring serves about170 households (850 individuals).

Following a request from Adigrat town Administration, SEUHP renovated a non-functional hand dug well. However, still after renovation, the hand-dug well was still not functioning. A team of individuals from JSI/SEUHP, the contractor, and an engineer from the town municipality conducted a site assessment and it was learned that it was Shallow Well and it didn’t have water even after renovation and this is because there are deep wells around this Shallow Well that were constructed by the town Water Office. Because of this, the team agreed not to do further rehabilitation.

Construction of public shower: One block shower with four rooms (one room for persons with disability), septic tank, and a water tanker having a capacity of 10,000 liter water storage was constructed and handed over to the St. Mary church administration. Training was provided for the shower management committee members at St. Mary church. Six male church students were selected from Abinet School to manage environmental health, attended the training. A chairperson, a secretary, and finance person were also selected and their roles and responsibilities were discussed on the management and proper utilization of the showers and latrines. The shower service is expected to serve around 300 church students and other communities in the church which will be elemental for eliminating waterborne diseases like scabies. UHE-ps are providing regular health education to users of the facility.

Table 12: Summary of WASH related performance indicators, Oct. 2017-Sept. 2018

FY18 Q4 FY18 FY18 FY18 Annual FY18 Q4 FY18 Q4 Indicators Performance Annual Annual Performances Target Achieved (%) Target Achieved (%) Number of workshops and dissemination forums held to advocate for improved 6 9 150.0 32 37 115.6 urban sanitation and management Number of people gaining access to an 3241 2041 63.0 25065 28,298 112.9 improved sanitation facility (latrine) Number of households assisted/supported in 6886 13046 189.5 42226 52,814 125.1 gaining access to safe Liquid Waste/Grey Water

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Disposal Facility

Number of households assisted/supported with 9255 13612 147.1 33156 43,937 132.5 gaining access to proper Solid Waste Management

5. OTHER KEY ACTIVITIES

5.1 U.S. Family Planning and Abortion requirements the USG PLGHA policy

In order to comply with USG’s statutory restrictions and policy requirements such as Protecting Life in Global Health Assistance SEUHP:

. Assigned focal persons who will coordinate efforts to insure the maximum response to family planning and abortion statuary and policy. . Reviewed and revised the existing family planning and abortion compliance plan based on the new developments. . Revised the existing family planning and abortion compliance monitoring system and tools . All eligible SEUHP staff took the family planning and abortion e-learning course and they received certificate of completion. . SEUHP’s Chief of Party, Technical Director and Monitoring and Evaluation Director attended a one full day training on family planning and abortion compliance organized by USAID in Addis Ababa. Following this training orientation is provided to the project staff. . The family planning and abortion compliance requirements clauses are incorporated into the contractual agreement of Emanuel Development Association’s sub-contract to SEUHP. . Incorporated selected family planning and abortion indicators into its structured supportive supervision checklist.

5.2 Partners Forum

In the reporting period, SEUHP participated in a meeting which was organized by Oromiya Regional Health Bureau. The aim of the meeting was to formally establish a strong partners` forum with all NGOs that are operating in the region. Eventually, the said forum was established by nominating a coordinating committee under the leadership of the RHB head. SEUHP had been registered as a key partner of the region and member of the forum.

5.3 Host USAID visit to Millennium Health Center and Harar Kebele in Hawassa

SEUHP hosted a team of visitors from USAID in the current reporting period. The visit was made to a health facility and a Kebele in Hawassa town focusing on both health facility and community based health services in Millennium health center’s catchment area and the role of UHE-ps and linkage between UHE-ps and the Health Center. During the visit, brief presentation was made by HC and Kebele officials followed by discussions. The visitors appreciated some of the interesting initiatives and the roles of UHE-ps in the community based health services. They also admired the existing strong linkage between the health center and UHE-ps. They also pledged

SEUHP FY 18 Annual Report 75 that USAID will continue supporting such community based health services including WASH. USAID visitors concluded their visits by providing umbrellas to UHE-ps working in Harar Kebele.

5.4 Participate in mid-term review of Health Sector Transformation Plan

In this reporting period, SEUHP regional teams participated on the Mid-term Review (MTR) of Ethiopia’s Health Sector Transformation Plan (HSTP-II) that was conducted by local and international consultants hired by FMOH. SEUHP team participated in the field work during data collection at Kebele or household levels. The team tried to make sure that urban health issues especially challenges related to the information system are included among the action points or recommendations of the review findings. The team used structured data collection tools. Besides, SEUHP team provided feedback on the draft reports of the review findings. Some of the recommendations included in the mid-term review report as part of the information revolution agenda of the Health Sector Transformation Plan include: setting clear strategies and policies for urban Health Extension Program (leadership and guidance expected from FMOH); introducing innovative approaches to information use; introducing accountability measures for HMIS data management (data entry, data quality, etc.); and scaling up best practices in data quality assurance and the likes to all levels of the health system hierarchy.

5.5 USAID officials visit to Primary Health Care Reform sites

SEUHP facilitated a site visit for USAID’s newly assigned Health Office Chief, Ms Rachael in Nifas Silk Lafto Woreda 06 HC. The officials visited the health center service delivery units, and discussed with health service providers as well as community representatives and briefed how the PHCU reform is structured and functioning and reviewed the nine months achievement of Family Health Team’s. Finally, the visitor provided her reflection and feedback for the health center leaders and community representatives.

5.6 Facilitated field visit for the US Ambassador in Ethiopia

US Ambassador to Ethiopia H.E Michael Raynor along with USAID’s deputy mission director, Alicia Dinerstein, USAID’s Health Office Director: Ritu Singh, USAID’s Health Office Deputy Director: Eshete Yilma, USAID’s

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Health Systems Team Leader: Dr. Helina Worku, visited SEUHP’s project sites at Hawassa town in Southern Nations Nationalities to observe Urban Health Extension Program implementation and JSI/SEUHP’s contribution.

SEUHP facilitated PHCU reform implementation site for the visit. The visit included a discussion with the health center, UHE-ps and community members at their household. During the visit UHE-ps demonstrate the roles of UHE-ps in the community health service, preparations for Family Health Team approach implementation which includes; catchment area baseline data collection, analysis and summarization, family categorization and selecting priority segments of population for service. It also helped to demonstrate UHE-Ps roles in community service as a multidisciplinary team of Family Health Team. Finally, key note address was delivered by RHB head and USA Ambassador.

5.7. Health champion recognition and support

In the reporting quarter, 30 community health champions, who have been selected from all JSI/SEUHP implementing towns in SNNPR were recognized for their contribution on health service and WASH activities through provision of certificates. Some of their contributions included: working with/ support UHE-ps in mobilizing the community during health and sanitation campaigns, improving the health service seeking behavior of their community, initiating and creating clean & green areas through mobilization of their village community, and giving care & support to people living with HIV & elders were among others. The certificate will motivate the health champions to continue their current engagement in health service activities and will encourage other community members to be like them as well.

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6. DATA QUALITY ISSUES DURING THE REPORTING PERIOD

Since FY15, SEUHP has been conducting data quality assessments or routine data quality checks using tools adapted from PEPFAR/USAID Data Quality Assessment tool. The data quality tools/plan has been used to guide rigorous checks on data quality as well as on the process of data management in SEUHP supported regions.

In FY18, SEUHP planned to conduct two rounds of internal rigorous data quality assessment in all SEUHP- supported regions. The first round of the data quality assessment was conducted in March 2018 in Addis Ababa (Arada and Nifas Silk sub Cities), SNNPR, and Oromia (Batu and Bishoftu towns and SEUHP Oromia regional office) regions. Electronic data collection was employed for the data quality assessment which was instrumental to facilitate real-time information and feedback systems for decision making. The electronic data collection approach served the instant information needs of the program to make improvements and facilitate timely decision making.

The data quality assessment aimed at assessing the completeness, accuracy, and consistency of data recorded and reported by UHE-ps by comparing it with data entered into SEUHP’s electronic database. The data quality assessment considered three Cooperative Agreement indicators: number of individuals “reached” with direct services, number of completed referrals documented in the reporting period, and number of defaulters identified and linked to health facilities for continuity of services in the reporting period.

In this regard, findings from each of the regions visited showed that there are huge improvements in data quality issues in every data quality dimension and the data quality assessment indicators are within acceptable ranges. Besides, documentation of Annual work plan (FY14, FY15, FY16, FY17 and FY18), Performance monitoring plan PMP), Detail Implementation plan (DIP), SEUHP regional profile, Annual and Quarterly reports (Quantitative data and Narrative), Data quality Assessment DQA) reports, Supportive supervision (SS), SIMS, SOPs, Manuals, Guidelines, standard tools, Job aids, reference tools, M&E tools, Success stories, data bases such as SRDT, PHCU reform, Training data base, SS and review meeting data bases were assessed based on the revised checklist.

Besides the data quality assessment, in this reporting period, SEUHP regional teams provided technical support to City/Town Health Offices to ensure the quality (completeness, consistency, timeliness, and reliability) of data recorded using Service Data Recording Tool at UHE-p levels. To this effect, SEUHP regional teams have been conducting regular data quality checks during data collection and supportive supervision visits to UHE-ps and their supervisors using the developed grading system in the supportive supervision checklist.

Data quality check observations show that there are significant improvements on the quality of service data recording and reporting including in line with completeness and consistency. Though the findings fall in an acceptable ranges, there incompleteness problems mainly because of failure of the UHE-ps to record all the services they were providing. To address these data quality issues, on-site mentoring and cleaning of recorded data were done.

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7. COMMUNICATION AND DOCUMENTATION RELATED KEY ACTIVITIES AND ACCOMPLISHMENTS

7.1 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, Regional Health Bureaus, City/Town Health Offices, Health Centers, and UHE-ps. 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.

. Documentation of success stories and best practices Documentation of best practices and success stories has been a continuous task. In the past three months, SEUHP documented numbers of success stories and best practices which are mainly about positive changes that are brought by the program on beneficiaries, including community members, UHE-ps, UHE-p supervisors, and city/town offices in Oromia and SNNP Regions. The documented success stories are about achievements in providing counseling and services on HIV, MNCH, WASH and Family Planning.

The best practices on the other hand are about the achievements brought to the services of health centers after applying QI, LMG and Job Aid utilization. The stories are documented in Butajura, Sodo, Arbaminch and Hawassa towns of SNNP and Batu and Shashemene towns of Oromia Regions. The stories are edited and being shared to SEUHP staff, stakeholders, and partners and used in different formats to encourage learning and to validate program achievements.

. Utilize website developed by AAU/SPH as one of resources sharing platform Addis Ababa University School of Public Health developed a website that will serve as a pool for resources on Ethiopia’s urban health such as studies and other resources. With the aim of using this website as one platform to share its activities and contributions with the general public, materials and resources produced under SEUHP are organized and loaded on the site. In addition, support has been provided in the general website layout designing, web content development and organizing process. Refer the link for details; http://urbanhealthethiopia.org/

7.2 Production of Documentary with EBS

Under the agreement between EBS, SEUHP has been working with EBS on the production of four (30 minutes each) Television programs on Urbanization, UHEP, and WASH. The documentaries got approval both from USAID and SEUHP and are aired on July 26 , 27 , 31 and August 1, 2018.

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7.3 Production of Newsletter

SEUHP’s quarterly newsletter (volume 3 of the first issue) has been produced. The contents of the newsletter include articles on the first national urban health conference; implementation of CHIS in urban areas, PHCU reform in Addis Ababa and so on. There is also news/updates coverage on the higher official’s visit to Thailand and the inauguration of WASH facilities in Amhara Region. The newsletter is distributed to FMOH, USAID, partners, City /Town Health Offices and SEUHP Regional offices. Besides, the softcopy of the newsletter will also be uploaded on the JSI’s website.

7.4 Participated in the Annual Review Meeting (ARM) of the health sector

The 19th annual health sector review meeting took place in Gondar, Amhara Region. More than 1,700 participants, from across the country’s various health sectors attended the meeting. The meeting was officially opened on November 8, 2017 and continued until November 10, 2017. At this meeting, SEUHP exhibited the program’s achievements and areas of support using different materials (job aids, factsheets, manuals, best practices and success stories, pictures, banners and rollups). SEUHP also made a special arrangement by which UHE-p demonstrated her day to day activities and how SEUHP’s support improved the quality of the services she provides. In addition, a side meeting that focused on the Primary Health Care reform activity was organized by SEUHP. State Minister Dr. Kebede, head of the office of the Minister; Dr. Meseret and Director of the Primary Health Service and Health Extension Program Directorate; Dr. Zufan, regional health bureaus heads, deputy heads, partners and other participated during the meeting. 7.5 Summary of SEUHP’s FY17 annual report prepared

A summary annual report that focused on SEUHP’s FY17 accomplishments, challenges, and lessons is prepared and being shared in softcopy widely.

7.6 Engaged in organizing Transform projects launching event

USAID and its implementing partners launched “Transform projects” in Ethiopia in an official launching event organized in Addis Ababa in October 16, 2017.

SEUHP worked with USAID and other implementing partners in organizing the transform projects launching event including designing of communication materials (banners, booklets), preparing speeches, program documentation and organization of the event in general. USAID designed TRANSFORM projects to strengthen implementation of Ethiopia’s health sector transformation plan by focusing on addressing preventable Maternal and Child deaths.

7.7 Supported WASH facilities inauguration event

With the support from USAID, SEUHP constructed WASH facilities in five towns, Kombolcha, Kemise, Sekota, Alamata and Adigrat as part of an emergency response in drought-affected urban and semi-urban areas. On December 2, 2017, Dr. Kebede Worku, State Minister of the Ethiopian Federal Ministry of Health (FMOH), and Dr. Abebaw Gebeyehu, Amhara Regional Health Bureau Head, inaugurated model Water, Sanitation, and Hygiene (WASH) facilities constructed in the towns of Kombolcha and Kemise towns. The model Water, Sanitation, and Hygiene (WASH) facilities in Sekota and Alamata were also inaugurated by their respective town administrators and stakeholders.

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7.8 Photo booklet production started

In FY18, SEUHP aims to visually document UHE-ps’ efforts, challenges, and successes through photography that will be shared with stakeholders, including the U.S. government, the government of Ethiopia, and others.

7.9 Attendance of the Strategic Information Workshop

SEUHP Communication and Knowledge Management Advisor and the Senior M&E&R Advisor participated in the JSI Strategic Information Workshop that was held from November 14 16, 2017 at Marrakech, Morocco. The objective of this workshop is for JSI projects worldwide to develop skills in strategic information-related areas, learn best and promising practices that can enhance project implementation, work with governments to increase their capacity to use information to benefit the health system, and to share experiences across projects.

Strategic information plan for SEUHP is prepared and progress is made towards preparing materials that will help to communicate strategic information about the project.

7.10 Branding and logo management

Branding of program activities is a compliance issue that SEUHP is required to ensure the appropriate management. In an effort to enhance recognition USAID’s and the American people’s contribution for their support SEUHP technical documents and communication materials including radio drama, radio magazine programs, brochures, and posters are being marked in compliance with the branding and marking protocol.

7.11 Website protocol and management plan developed

With the aim of making urban health related resources available and accessible for all interested researchers, policy makers, and programmers working on urban health related issues, AAU/SPH has launched a website. As there is no website dedicated specifically for urban health related issues in Ethiopia, dedicating a website specifically to share evidences on Ethiopian urban health, updates from the urban health The first website dedicated for Ethiopia Urban health issues is established by advisory group (established under this School of Public Health/ Addis Ababa University with support from SEUHP project), to post call for researches and conferences (to be organized by the center), and other resources is believed to be significant. This website will be managed by this center to serve as a resource pool on urban health in Ethiopia including journal articles, guidelines, and policy briefs.

To simplify and to ensure efficiency and clarity of communication conduit among the various responsibilities in the web content management process of “Urban Health- Ethiopia” website, a web content management protocol is developed. The protocol is intended to help streamline communication amongst the website content providers, editors, approvers and updaters. The website protocol includes a web content management plan.

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8. OPERATIONS AND FINANCE: KEY ACTIVITIES AND ACCOMPLISHMENTS The following is a detailed description of key SEUHP operations and finance-related activities during the first quarter of FY18. 8.1 Administration

Implementation of the FY18 work plan: The operations team supported activities to support the technical implementation of the program in its final year. Key areas that the team supported include the following: (1) Administrative and logistical support provided for the Strengthening Urban Health Extension Program/SUHEP/ workshops, Leadership, Management and Governance/LMG/ Training, Media Engagement review meeting and WASH LMG training at various SEUHP implementation sites in Addis Ababa, Oromia, and Amhara regions. (2) Supported the Federal Ministry of Health in organizing the Second round National Urban Health Conference that was held on May 15, 2018. Followed by the Health Extension Program Advocacy workshop, held on May 16 & 17, 2018 at EPHI conference hall with the presence of higher officials. (3) Final FY18 annual work plan is shared to central and regional offices after incorporating the technical team’s comment. (4) Supported the organization of a Structured Learning Visit to Thailand from October 29 to November 04, 2017. (5) Maintained staff safety by introducing security measures while they travel and implement their day-to-day activities and develop one pager staff safety and security measures. (6) Attended the UNDSS security update 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: The vehicles annual inspection, vehicle insurance and service is up to date. SEUHP uses GPS in managing the fleet/vehicles besides internet connectivity problem.

Fleet/vehicle management: The vehicles annual inspection, vehicle insurance and service is up to date. SEUHP uses GPS in managing the fleet/vehicles.

Procurement: The following are major procurement and printing related activities in the reporting period: (1) Printing materials – The following materials were printed and distributed:1,406 copies of Service Data Recording Tool for Amhara, Oromia and Tigray, 1,919 pads of referral slip, 203 copies of different IRT materials1,350 copies of Newsletter, 800 copies of WASH LMG training manual, 200 copies of Primary Health Care Reform Implementation Guide (Booklet), 960 copies of Family Health Team, 104 copies of Certificate for LMG for participants and Health center at SNNP and 20 copies of certificate of appreciation for Media personnel for their participation and contribution of Addis Ababa Administration, 3,600 copies of UHEP implementation manual and 35 copies of PHC reform guideline, 500 copies of each Proceedings and Summary notes from the First National Urban Health Conference, 3 pcs of Banners and 1 pc of Roll up banner for the Second round National Urban Health Conference. (2) Renting vehicles – JSI SEUHP rented vehicles to transport staff to various workshops, supportive supervision, and field visits. (3) Furniture, computers and supplies -Office Stationery and other small items (UPS battery 12,7amp, memory card for photo camera, HP toner 35A,85A and 05A, toners for PH 1102, divider with long cable, flash disk, CD- RW label ,Toshiba laptop screen and others) were procured and distributed for use.

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(4) Construction: SEUHP completed the construction of hand-dug well, public latrine and shower facilities in three geographic areas: lot 1- Sekota and Alamata and lot 2- Kombolcha and Kemissie. And the construction of hand dug well, public latrine and shower facilities at Adigrat town is completed during this reporting period. The first retention fee payment was released for lot I- construction sites after doing the minor corrections that was commented by Tetra tech and the regional town health offices.

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

Meeting/Communication with USAID: SEUHP‟s COP and management team met with the project’s alternate AOR (Dr Helina), Ato Eshete, and Dr Yosef (SEUHP‟s AOR) to discuss major achievements of FY2017‟s Annual Progress report and key activities planned for the FY 2018.

During the reporting period, JSI SEUHP submitted the following reports to USAID; SEUHP FY 2017 Annual Progress Reports, SEUHP quarterly Accrual Report, SEUHP obligation increase letter, re-planning request to approve for the construction activities related to Water, Sanitation and Hygiene (WASH) facilities, request to approve FAA mechanism to AAU/SPH, SEUHP Quarterly SF 425 and Expenditure Analysis report for FY 2017, SEUHP Family planning and Abortion compliance report and SEUHP Environmental Mitigation and Management Plan. SEUHP also received; point of contact at USAID, Modification 12 for the incremental funding, and Modification 13 for no cost extension approval from July 01, 2013 to March 31, 2019 and Modification 14 to drop the construction of ten public latrines and to inform the AOR and Alternate AOR change.

8.2 Human resources

Staff benefits: annual employees’ life and medical insurance agreements were renewed and various insurance processes such as inclusion, removals, family additions, medical refunds are updated. All changes to the salary of the staff should be communicated to the Private and pension fund Authority. Besides, all employees’ life and medical insurance agreements were renewed till the end of their contract of employment that is Nov. 30, Dec. 31 and March 31, 2019 as per the new modifications we received from USAID. Various insurance processes such as inclusion, removals, family additions, medical refunds are updated.

Performance Evaluation: annual performance reviews were conducted for eligible staff and their salary is adjusted accordingly.

Job Reassignments: Four positions were filled that is AA Monitoring & Evaluation Advisor, Oromia Monitoring & Evaluation Advisor, Tigray Monitoring & Evaluation Advisor and Quality Specialists in addressing the upcoming final evaluation of the program.

New staff: Anew staff member joined JSI SEUHP in replacement of the previous Cluster Coordinator at Adama in this reporting period and one additional data encoder is also hired.

Termination of employees: During the FY 2018 reporting period, two JSI SEUHP staff (WASH Engineer and WASH cluster coordinator) contract is terminated as of Dec. 31, 2017. Moreover, two KMC staff members and five Evaluation Assistants contract is terminated due to project closeout. Moreover, two KMC staff members and five Evaluation Assistants contract is terminated due to project closeout. Three months termination notice letters are prepared and dispatched to all regional cluster coordinators. All fifteen staff, whose termination of employment was ended in June 30, 2018 and communicated their termination of employment agreement to the Private and pension fund Authority and Awash Insurance Providers. All staff members, whose termination of

SEUHP FY 18 Annual Report 83 employment was ended in November 30, 2018, are given a three month termination notice. Staff who resigned from SEUHP before their end of their contract period was communicated to the Private and Pension Fund Authority and Awash Insurance Providers.

8.3 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. Moreover, JSI launched a new Admin notice to all JSI International Division staff to comply with the requirement to maximize the use of electronic payment systems on all awards regardless of funder; and to set a ceiling on cash advances issued in the field effective November 17, 2017. Therefore, SEUHP has transitioned to electronic payments for transactions. Expenditure analysis report: SEUHP uploaded the expenditure analysis report on the promis database on Nov. 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.

All the SEUHP finance team at the Central and regional office have attended a closeout meeting every month based on the closeout plan checklist that was prepared by JSI in line with the USAID closeout guidance and SEUHP’s cooperative agreement.

8.5 Partnership

AAU: A new Fixed Award Amount /FAA/ contract is awarded starting from January 01, 2018 to June 30, 2018. AAU SPH conducted two research studies and the principal investigators for the two research projects were presented at USAID office to share their research findings to USAID Journal club members on Feb. 22, 2018. AAU SPH received a formal notification and instructions of the closeout by beginning of April 2018.The letter stated that the end of the FAA would be in June 30. However, due to many competing priorities from both offices (FMoH and AAU School of Public Health), the Fixed Award Amount /FAA/ contract is extended till August 31 with no cost extension. AAU completed all of its program activities as of Aug. 31,2018 and as per the notification letter, we are waiting to receive all the necessary project narrative report, datasets, electronic copies of all reports, abstracts, and publications and related documents by September 30, 2018,

EDA: A contract modification is signed with EDA in this reporting period for two purposes; one to increase the obligation fund and the second one is to extend the period of performance to end of July 2018. EDA received a formal notifications and instruction of the closeout by the beginning of April 2018. This notification explained the final date of the termination of the contract would be June 30 and to deliver all the required deliverables as per the agreement we had with EDA by July 31, 2018.As per the closeout plan notification letter, EDA handed over all the reports to SEUHP. The reports they submitted were Performance report; Final Inventory list; Final Financial Report and cost share documents.

Harvard T. H. CHAN School of Public Health: JSI SEUHP has been working closely 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. The KMC project ended on Dec. 31, 2017. All the staff contracts for this project were terminated and the final termination payments were effected. Moving forward the remaining project activities of the KMC project will be implemented through Addis Ababa University School of Public Health.

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8.6 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. All procurements were regularly inspected for compliance. Visual compliance was taken for new hired staff and vendors.

8.7 Closeout

A draft summary closeout plan was submitted to USAID and SEUHP will take action based on this plan. Hence, the 1st major staff downsizing will happen in June as all cluster coordinators will leave the project as of end of June 2018. In addition, SEUHP will start disposition of project equipment that don’t require USAID’s approval starting from July 2018. As per the closeout plan, major staff downsizing happened by the end of June when all cluster coordinators left the project. The second phase of staff who will resign on Nov. 30, the third will be departed on Dec. 31 and the final crew staff will be departed on March 31.

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9. CHALLENGES AND PLANS TO OVERCOME THEM DURING THE REPORTING PERIOD

Challenges Proposed Solutions We are accelerating project implementation Security problems particularly in Amhara, SNNPR, taking advantage of the relative stability that is and Oromia regions. This has slowed down observed after the election of the new Prime project implementation. Minister.

Competing government priorities including at City Flexible planning arrangements Town Health Offices, Health Centers and UHE-ps level hindered implementation of our plan.

Internet connectivity fluctuation affected our Used other means of communication including communication. telephone and mail services. Frequent change of government officials resulted Keep-up with updating newly assigned officials in low performance particularly with regard to about the program and make all the necessary WASH activities. effort to generate their support.

High UHE-ps turn over and replacement by Provide orientation and organize mop-up training professionals that are not trained on UHEP for newly assigned UHE-ps.

High expectation of financial support from Discussing and convincing the Town JSI/SEUHP when they implement WASH–LMG by Administrations and participants to plan and WASH sector offices implement LMG–WASH project by their own resources to ensure suitability. High level of expectation for support from FMOH We are informing the government our status and and regions while SEUHP is in closeout phase. what we can do with the available resources. We hope they will understand our situation.

10. MAJOR ACTIVITIES PLANNED IN THE NEXT REPORTING PERIOD

The following section summarizes the major SEUHP activities planned for the first six months of FY18. Activities are presented in line with SEUHP's intermediate and sub-intermediate results.

IR 1: IMPROVED QUALITY OF COMMUNITY‐LEVEL URBAN HEALTH SERVICES Sub IR1.1: Improved knowledge, skills, and motivation of UHE-ps 1.1.2 Support FMOH and RHB in implementing UHEP Optimization process Sub IR 1.2: Improved UHE-ps' access to standard health service delivery packages and service standard manuals 1.2.1 Support Contextualization of Woreda Transformation Standards and Tools into the Urban Context 1.2.2 Support FMOH in the piloting of PHC clinical guideline in PHC reform implementation areas

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1.2.3 A national level review meeting will be conducted with all implementing health centers in October 2018 to ensure full ownership 1.2.4 Support FMOH in Finalizing the Development of UHEP`s Logistics/ Supply Management Guideline Sub IR 1.3: Improved implementation of QI initiatives 1.3.1 Organize one consultative workshop to finalize the draft national Community based QII implementation guideline. Sub IR 1.4 Support FMOH and RHBs in the implementation of PHCU reform in selected sites 1.4.1 Technically support FMOH and regions in finalizing the PHCU reform implementation guidelines and tools and getting them ready for large scale implementation.

IR2: INCREASED DEMAND FOR FACILITY-LEVEL URBAN HEALTH SERVICES

Sub-IR 2.1 Implement strategically-designed behavior change communication interventions 2.1.1 Collaborate with national and regional media to organize and air panel discussions on urban health focusing on giving the required attention to urban health 2.1.2 Share electronic copies of all technical documents to FMOH, RHBs, C/THOs, and HCs to ensure its continued use at different levels Sub IR 2.2. Produce and air radio programs to promote and model key RMNCH, HIV, TB and WASH-related behaviors 2.2.1 All radio programs produced by SEUHP will be handed over to RHBs and UHE-ps so they can be used by UHE-ps to educate local community members 2.2.2 Support Addis Ababa RHB to organize a review meeting of media and assist them technically to produce and air need-based programs on urban health issues

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, zonal health departments, and C/THOs 3.1.1 Conduct one round of JSS in collaboration with FMOH and RHBs to bigger towns with populations greater than 100,000 to enforce implementation of the key recommendation of the health extension program optimization. 3.1.2 Organize Regional Level Urban Health Forum in All SEUHP Regions 3.1.3 Organize SEUHP’s End of Project Lesson Dissemination and Project Closeout Forum Sub-IR 3.2: Improved urban health data collection, analysis, and utilization 3.2.1 Support Implementation of Urban Community Health Information System in SEUHP Target Cities/Towns-support TOT for scale up of UCHIS 3.2.2 Generate Evidence on Urban Health and disseminate study findings and lessons at International forums 3.2.3 Electronic datasets will be handed over to the respective RHBs and/or towns as part of SEUHP’s close out process Sub-IR 3.3 Knowledge management: Documentation and sharing of program lessons to governmental stakeholders 3.3.1 Digitalization (e-Copies) of all SEUHP related documents and sharing with FMOH, RHBs, C/THOs, HCs, UHE-s 3.3.3 Produce photo booklet. 3.3.4 Essay writing competition among UHE-ps. Sub IR 3.4 Strengthened Individual and Organizational Capacity of Partners to Perform Core Functions of UHEP 3.4.1 Facilitate the Capacity Development of SEUHP’s Sub-grantee Emanuel Development

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 Organize an event for Oromia regional sector bureaus to sign the customized MoU of IUSHS

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4.1.2 Share the key lessons and challenges to higher officials at the regional urban health forums. In these forums, mayors with better experience in sustaining WASH platforms will share their experience. 4.1.3 Provide all the materials, guiding documents, success, and challenges to the respective RHBs with orientation so they can continue providing support to the platforms established in the different towns. They will also be advised to scale-up the initiative to other towns Sub IR 4.2: Increase supply of low-cost sanitation and hygiene products, facilities, and services 4.2.1 Organize a one day national level advocacy workshop to familiarize the PPP models to stakeholders Sub IR 4.4: Increased knowledge base to bring WASH Innovations to scale 4.4.1 Document and Share Best Practices and Lessons

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Annex 1: Major Accomplishments Based on Action Plans Developed During the Town Level Workshops in the Regions Oromia Amhara SNNPR Tigray

 31(83.8%)of HCs assigned  17 (50% of HCs)  20 (80%) of HCs assigned UHEP  HC staffs in 3 towns were focal persons for HEP. relocated UHE-ps supervisors and supervisors oriented on implementation  33 (89%) of HCs assigned from Kebele to started checking the utilization manual (Alamata, Aksum, HCs staff to support Health center of UHEP toolkits. Shire). UHE-ps. compound  33 (89%)of HCs provided providing them  5(46%) of SEUHP supported  UHE-ps duty stations were orientation on toolkits their own office towns oriented stakeholders arranged in two kebelles in and revised UHE-ps IM to space. (mostly kebele administrators) Alamata. relevant staff of HC on the revised UHEP  Budget allocated through  6 (16%) of HCs started  16(47%) Health implementation manual focusing town/city cabinet to procure provision of supplies. Centers provided on their role and responsibilities. & deploy eight additional  36 (97.3%) of HCs supplies including  17 (68%) of HCs showed UHE-ps in Alamata, Maichew, started regular Glucometer, HCG, improvement on their support Adigrat, & Aksum. supervision and technical first aid kit, and iron from HCs to UHE-ps (SS,  Health center staffs were support to UHE-ps. folate to UHE-ps. provision of medical supports, assigned to support UHE-ps  27 (73%) of HCs started  11(32%) Health etc…) including technical in Alamata, Maichew, Aksum, regular review of UHE-p. Centers are support. and Shire.  29 (78.4%) of HCs providing  19 (76%) of HCs referral  Technical support from town developed checklist to comprehensive activities improved (focal health office experts and/or support UHE-ps. service list. assigned, referral folder provided Health center staff has  7 (19%)of HCs started  32(94%) HCs for each case team and progress improved in Alamata, conducting DQA assigned one health followed. Maichew, Aksum, and Shire. center technical  Metu health center has  6(55%) of SEUHP supported  UHE-ps were reshuffled to staff to 2 UHE-ps to procured and provide towns started to conduct optimize their work in provide weekly first aid kit to UHE-ps pregnant women conference and Alamata. support. UHE-ps are able to get support  Mendera Kochi health  UHEP supportive supervision  24(71%) the HC are of midwifes. centers of Jimma towns checklist is conducting weekly have addressed the duty  4 (36%) of SEUHP supported contextualized/customized to performance review station problem of two towns started to conduct local context in Alamata. meeting regularly. UHE-ps (Sato Samero and quarter review meetings by their  Data collection & households Ginjo Guduru) by  34(100%) UHE-ps own resources. categorization is started in communicating with are using the  8 (32%) of HCs have been Aksum and Shire. kebele leaders. standard recording showing improvement on data tool for daily  Four health centers at use and management activities, services provision. Bishoftu have started for instance: copy of under 1 and provision of supplies to  33(97%) of HCs pregnant mothers registrations UHE-ps including first-aid review UHE-ps printed and distributed which kit. performance on can be used for at least one year weekly and regular at Hosanna town. basis.

Dire Dawa Addis Ababa Harar

 9 new UHE-ps are  Orientation training has been provided on UHEP IM  All UHE-ps providing service assigned to address for HC staff, heads of Woreda Health Offices and based on the revised UHEP human resource other stakeholders at 34 HCs (85%). Follow-up was implementation manual. challenge. also conducted by these HCs on its availability and  6 HCs provided office utilization.  4 (100%) HCs relocated UHE-ps’ furniture (table. chair and duty station from kebele to

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computer) for UHE-Ps.  Twelve HCs (70.6%) have facilitated on-job training Health center compound.  HC staff started actively and clinical attachment for UHE-ps. This will enhance  In 4 (67%) out of 6 Woreda linking the list of mothers UHE-ps capacity to deliver newly added community Health Offices, UHE-ps are who gave birth at health level health services like PNC and FP. serving the community as per the center level to UHE-Ps  13 HCs (46.4%) have integrated UHE-ps supply needs standard per day (8 HH) reached for further follow up. on the HCs plan and budget. Two HCs in Yeka SC by UHE-ps.  Timeliness of HH level provided first aid kits and other supplies.  Household categorization being solid waste collection  One-third (65%)of these HCs have started monitoring implemented according to disease improved UHE-ps daily and are checking whether UHE-ps use and income status at 2 out of 4  Weekly and monthly job aids at hand while giving services in the HC (50%) (Jinella and Amir Nur UHE-ps performance community. HCs-PHCR sites). review started and  Among those who planned 17 HCs, 65.4% have  3 (75%) Health centers providing strengthened. strengthened the referral system through services for school, youth center,  Utilization of supportive implementing different strategies including (but not and hard to reach population by supervision data for limited to) give attention to clients with referral slip, UHE-ps and HC technical support performance sign interface with nearby HCs to collect and provide staff. improvement improved. feedback and use the morning session to discuss daily  In majority 6(83%) of WoHOs,  More attention being referral related issues. UHE-ps are utilizing tool kits/job given for improved data  One-third (35 HCs- 77.8%) of the total HCs have aids during community level quality. started to conduct regular monthly meetings to service delivery. review UHEP. Moreover, these HCs have  SS conducted regularly for UHE- strengthened the all staff as well as program specific ps in 3 (50%) of the WoHOs. monthly meeting regularity.  All the 4 HC and 2 C/THO  Majority (43 HCs) health centers have planned to 6(100%) conducted regular strengthen the SS practice by using a standard review meetings for UHEP. checklist. Among these HCs, 34 (79.1%) of them have  1(16%) of WoHOs utilized 1 to 5 accomplished this activity while the rest are in network structure for the progress. implementation of UHE package  About (62.8%) of HCs have started to monitor daily service data recording and reporting tools utilization.  Almost all the Woredas 6(100%) Supervisors in these HCs have also started to conduct had planned for the printing of monthly LQAS for UHE-ps individual report. The SDRT and referral slip using their filled LQAS tools are being submitted to sub-city own budget. health office attached with the SDRT.  4 (66%) Woreda health office and HCs have adapted the UHE-ps, HCs, and HH level SS checklist

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Annex II: SEUHP Strategic Information Action Plan 2018

What we want to show Data point to use Audience Channel

Sub-narrative 1: Tell the story of leadership, management and governance supported

Pictures Higher level leaders (ministry to HF) Commentary (JSI website and blog, ARM 2018 and getting on Leadership and governance of urban PHCU leaders, Donor (USAID and local newsletters), and 1 HEP: successes, challenges and Testimony of the individuals others) and partners manuscript opportunities Health center base line and performance

data Reports Donors SEUHP’s contribution to bringing attention to the bottlenecks of UHEP Presentations Higher level leaders 2 Commentary challenges (policy change through minutes of the conference, HRH advocacy management of the UHEP assessment, HEP optimization, IM revision

Sub-narrative 2: Tell the story of urban health professionals capacitated

Technical brief- to talk about the process of the IRT Higher level leaders (ministry to HF) Story of IRT training and supportive Training data base, Pictures, Testimony 3 PHCU leaders, Donor (USAID and supervision, job-aids and SOPs provision of the individual _ UHE-p Case studies (JSI website and others) and partners blog, ARM 2018 and getting on local newsletters),

Sub-narrative 3: Tell the story of access to quality health services increased What we want to show Data point to use Audience Channel

Technical brief Presenting Baseline data, progress reports, Minutes Implementation of QI in UHEP: what FMOH, RHB and CTHO, PHCUs and lessons on conferences, 5 and evaluation assessment report worked, what didn’t, and why? partners/donors manuscript Field visit Case study Manuscript

Monthly reports, Baseline assessment PHC reform: learning from early FMOH, RHB and CTHO, PHCUs and Technical brief 6 (Categorization), and evaluation implementation experience partners/donors assessment report, field visit Case study (Harar or Addis Ababa)

A strong linkage and integration created between HC and UHE-ps including FMOH, RHB and CTHO, PHCUs and 7 RM and SS reports Technical brief + website blogs referrals, technical support mechanisms, partners/donors etc…

Success story / repackaging Communities who benefited quality blog MNCH, HIV/TB and NCD services from Success stories Donors, PHCU and UHE-ps level Photo essay (one for each UHE-ps. 8 thematic area)

Sub-narrative 4: Tell the story of evidence generated, shared and used for decision making, policy formation and resource allocation

Publication in peer reviewed FMOH/RHB/C/THO journal Urban Community Health Information Focus Group Discussion (4), Key Scientific community/public health 9 System: lessons from the pilot-testing in Dissemination workshop Informant Interview (6) professionals Addis Ababa, Bishoftu and Hawassa Partners (NGOs) Scientific Abstract presentation

Rapid assessment, Desk review, Donor/USAID One pager using Info graphics 10 SEUHP’s achievement in the last five years program data analysis JSI/SEUHP staff

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What we want to show Data point to use Audience Channel

FMOH/RHBs, Partners Closeout workshop Contribution of SEUHP to Community Series of Case studies, Pictures of filing FMOH/RHB/C/THO, UHE-ps, Policy brief + blog from the 11 based data collection, analysis & utilization system, Key Informant Interview Donor/USAID, Partners manuscript

Sub-narrative 5: Tell the story of demand creation for health care

What BCC approach is best for Urban health in Ethiopia? A manuscript that Other NGOs and development partners cross analyzes the BCC approach that including USAID and other donors 12 SEUHP applied for urban health and Design document for Radio Serial drama Manuscript recommend others? FMoH, RHB communication team

Sub-narrative 6: 5. Tell the story of WASH development in urban spaces Mayors' engagement is key for urban Case study, Project report, National Case study ( Blog ) Technical WASH activities! Urban health conference proceeding Mayors and seven signatory ministries brief- on WASH platform 14 report Lesson from Public latrine business management model pilots U(include unemployed women start to manage public sanitation and hygiene Town level SME offices and SEUHP MoWIE, C/town utility heads, WASH Develop case study and 15 facilities(public latrine with shower)and report- sector actors technical brief, And manuscript generate income and improved sanitation and hygiene services in the community they are working)

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Annex III: Summary of Measurable WASH LMG Result Achievements in selected towns of Amhara region between June and September 20181

SN Sectors Measurable result Achievement Debre Markos 1. Health team To increase improved latrine 40% (among 272 HHs, there was only construction in Debre Markos town 68 HHs with improved latrine and Kebele 02 village 03 from 25% to 30% September 108 HHs have improved at the end of June 2010 latrine.) 2. Water and To increase safe water coverage from 77% (the team achieved 62.5% from sewerage utility 72% to 80% by June 2010. their plan). office 3. Urban agriculture To increase projects’ EIA certification 24%. (During baseline, 6 from 64 & environmental coverage from 10% to 50% at the end projects had EIA certification but in protection Team; of June 2010 Sept 15 projects have EIA certification.) 4. Culture, Tourism, To increase proper liquid waste 45% on Food and Drinking youth and sport management from 30% to 50% on establishments. (9 of 10 managed office team; Food and Drinking establishments (10 their liquid waste properly) in numbers) at the end of June 2010. 5. Trade and market To increase solid waste proper 88%. (During base line assessment, no development office storage from 0% to 80% on service any service delivery institution have team; delivered institutions (100 in dustbin in appropriate area but by numbers) at the end of June 2010. Sept 108 services delivered institution have dustbin.) 6. Education office To increase solid waste proper During base line assessment, no team; storage and link to solid waste school have dustbin in appropriate collection association from 0% to area but now 11 schools prepared 68.4% on schools (13 in numbers) at proper storage dustbin and link to the end of June 2010. solid waste collector associations.) The team achieved greater than 84.6% from their plan. Bahir Dar 7. Health team; To increase model family graduation The team achieved the measurable coverage in Tana sub-city zone D result from 29% to 60%. village from 29% to 85% at the end of June 2010 and make the village model 8. Water and To increase latrine coverage at water The team achieved latrine coverage sewerage utility source sites (11 in number) from 20% from 20% to 25% (during base line office Team; to 75% at the end of June 2010. assessment from 20 water sites only 4 have latrine facilities buy know 5 have latrine facilities). 9. Beautification and To increase solid waste collection The team achieved increment of solid Environment coverage from 85% to 90% at the end waste collection coverage from 85% protection of June 2010. to 90%. That means the team department Team achieved 100% of the plan

1 These are only samples; otherwise, there are so many measurable results that were reported from AA and SNNPR as well. 10. Education To create model 11 schools from 20 The team achieved 11 schools are Department team; primary and secondary Government model in WASH activities reach 55% schools at the end of June 2010. from all schools. That means the team achieves 100% from their plan 11. Amhara mass- To developed and air 6 episodes The team achieved 50 % of their plan. media team; about Urban WASH with different However, the team is not yet medias and to documented and air documented and aired other WASH each team activities at the end of June LMG team activities. 30/ 2018. Dessie 12. Health team; Decrease the number of private and 85 private and government government organizations who organizations connect the liquid connects septic tanker to the town waste to septic tank. the team rain water canal from 200 to 50 by achieved 56.7% from their plan June 2010 E.C. 13. Water and Reduce water supply contamination Reduced water supply contamination sewerage utility rate in distribution line by 20 % at the rate in distribution line by 18.2 %. office Team; end of June 2010. That means 91.4% from their plans 14. Environment To increase solid waste management Achieved increment of solid waste protection and coverage from 55% to 85% at the end management coverage from 55% to beautification of June 2010. 75%. That means the team achieves department Team; 66.7% from their plan. 15. Code of enforce To decrease improper liquid and solid Achieved proper solid and liquid Department team waste management on different trade waste management on 2320 different institutions and HHs from 20,000 to trade establishments and HHSs. That 10,000 (50%) at the end of June 2010. means the team chivies 23.2% from their plan 16. Education To increase hand washing practice Achieved increment of hand washing department team; after using toilet from 6% to 31.15% practice after toilet from 6% to on schools (19 in numbers) at the end 34.5%. (During base line out of 58 of June 2010. schools only 4 schools are practicing hand washing but now are 20 schools).

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Annex IV: Best practice

Semen Health Center Tackling Challenges using Leadership, Management and Governance Training

A client of Semen health center, mother of a three year old boy, Demekech, witnessed better service provision at Semen health center after LMG training.

Demekech G/Cherkos, 32, took her 3 years old boy to Semen Health Center as he was not feeling well and lost his appetite. Though Demekech gave birth at a hospital in another town, this was not the first time for them to visit Semen Health Center. She said her son took all his vaccinations in there. However, this time she went to the Health Center for another service and she was very satisfied with the services that she got. “I didn’t know how to get a card and that took a little of my time. Otherwise, the service that we got is really good,” added Demekech. Semen Health Center is among the 11 Health Centers in Mekelle Town, Tigray Region. Located in Ayder Sub City the Health Center serves over 40,000 people within four ketenas. Semen Health Center is also among the 14 Health Centers where SEHUP organized Leadership, Management and Governance (LMG) training. The main purpose of the training is to build urban health leadership capacity and identify and address gaps in the primary health care unit. Extensive waiting time to draw patient cards from the shelf; low TB detection rate; low facility level delivery; and lack of inventory and providing code number to medical supplies were the gaps identified by the staff while

SEUHP FY 18 Annual Report 96 taking the training. The training helped the staff to come up with an action plan to minimize and remove the identified gaps.

Increased TB Detection Rate The TB detection rate at the Health Center was only 70% when the staff started taking the first round training which was in January 2017. A month after the training the detection rate rises up to 80% and currently it reached 95%. “The progress is mainly because we have started working very closely with Urban Health Extension Professionals (UHE-ps) as they are the ones who have the first and direct communication with patients. We are planning to make it 100% shortly. We have achieved this because we have started working as a team because of the LMG training,” explained Leality Medhin, TB Focal Person at Semen Health Center.

Improved Facility Delivery Though there is only two home deliveries detected at the Ketena where the Health Center is located, the service delivery was very minimal. According to Michael Kahesay, Disease Prevention Unit Team Leader, the main reason for this was lack of awareness. Hence, the staff worked with different stakeholders such as UHE- ps and Women and Children’s Affairs Office of the town. As a solution, the staff comes up with the idea of identifying pregnant mothers with the help of UHE-ps and conducts a monthly meeting with them. “A mother should attend the conference at least three times within a month. This helped us to identify pregnant mothers in the catchment area as well as in teaching the mothers that they should deliver at the Health Center,” added Hailu Mezgebe, HEP Supervisor. The delivery room was another problem that pushed mothers to look for other convenient places for delivery. It was a one roomed house which was separated into two by a curtain. Mothers who went there for delivery didn’t have any privacy and three of them needed to stay in the same part of the room. Taking this into consideration, the Health Center in collaboration with the district constructed partition using aluminum.

Computerized Patient Cards A few months back, it would take from 4-6 minutes to get a card for a patient. This caused anger for many patients as people are time conscious and would like to receive services at health facilities as fast as possible. After identifying the problem, the staff started working to satisfy their customers and currently, they have computerized patient cards which reduced the time to 2 – 3 minutes. It also helps the card room area to be less crowded which had have fewer queues. “Currently, we are working even on weekends to make the patient cards computerized as we have about 5000 cards which are not yet computerized,” elaborates Adanech Hailemichael, Director of Semen Health Center.

The Health Center has 46 technical and 27 administrative staffs. Among the technical staffs 10 of them are Urban Health Extension Professionals. According to Adanech, the staff meets the UHE-ps every week and the supervisor is part of the daily morning meeting. This creates a strong relationship between the Health Center and the UHE-ps which results the community living around to be aware of the services the Health Center provides.

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