A Case of Ethiopia Abebe Gebremariam (MD) Binyam Fekadu ( Bsc ., MPH)

1. Technical Consultation on the Role of Community Based Providers in Improving Maternal and Newborn Health A Case of Ethiopia Abebe Gebremariam (MD) Binyam Fekadu (Bsc., MPH) • May 30 – 31, 2012 KIT,Amesterdam, The Netherlands

2. Outline • Background • Health Extension Program • Maternal and Newborn health in Ethiopia(MaNHEP)activities

3. Ethiopia • Ethiopia is Africa’s oldest independent country. • Covering 1,104,300 square kilometers • Borders with 6 countries • Geographical diversity ranging from 4,550m above sea level to 110m below sea level. • More than half of the country lies above 1,500 meters • The predominant climate type is tropical monsoon

4. Ethiopia Total population of 79.8 million. 83.6% rural 44% are under 15 years, 3% over age of 65 years. Average lifetime fertility 5.4 births Annual population growth rate is 2.6%.

5. Maternal and newborn Health Problems MMR 676/100,000, it is still among the highest in the world (2011 EDHS) The major causes of maternal death: • Obstructed/prolonged labor, • Ruptured uterus , • Severe pre-eclampsia/eclampsia , • Malaria, • Complications from abortion Newborn

6. Newborn Health Status • Remarkable reduction in infant and under-5 mortality • Little change in neonatal mortality -37/1000 (EDHS 2011) • Half of newborn deaths occur within the first 24 hours after birth • Three-quarters of all deaths within the first week of life • Higher NMR in rural area Major causes on neonatal mortality • infections (46%) • Birth asphyxia (25%) • Complications associated with LBW (17 %)

7. Shift in Strategy • Health Sector Development Program – 1997/98 • Review of HSDP I revealed that essential health services have not reached the grass root level • No significant improvements in: • Overall disease burden • Maternal and child mortality • Government introduced the Health Extension Program (HEP) in 2004 • Core component of the broader health system • Overall goal – create a healthy society and reduce maternal and child morbidity and mortality rates.

8. Health Extension Program (HEP) • Package of basic and essential promotive, preventive and selected high impact curative health services targeting households; • Focuses on households at the community level, involves fewer facility-based services; • The philosophy of HEP is that if the right knowledge and skill is transferred to households, they can take responsibility for producing and maintaining their own health; • The main vehicle for bringing key maternal, neonatal and child health interventions to the community • It includes Health Extension workers and their supervisors, Voluntary community health Promoters and model family

9. HEP Package

10. Health Extension Workers (HEWs) • High school graduate females • one year of training, • 2/5000 people • provide basic curative and preventive health services in every rural community. • On a government payroll • Each HEW is supported by 10 volunteer Community Health Promoters and model families • Supported by nearest Health Center/District Health Office

11. Cumulative number of HP and HEWs, FMOH

12. Voluntary Community Health Promoters (vCHPs) • Recruited by DHO,HEWs and community members • Support the HEWs • Implement full HEP packages • Each VCHP is expected to have 30 to 50 households • 40.2% of them served as TBAs/CBRHAs or other CHWs FMOH, UNICEF. Health Extension Program Evaluation, 2010

13. Model Families Expected to : • Practice health actions for themselves • Show the benefit they gained for neighbors/relatives/peers • Communicate health actions to the community • Refer to health facility/HEW • Be role models for change

14. Contributions of the HEP

15. Contributions of the HEP

16. Further Efforts to Improve Coverage and Quality of Services • Strengthen Primary Health Care Unit • Health Development Army/Women Development Army • Integrated Refresher Training • Community HMIS • Different Community Based MNH interventions – e.g. MaNHEP project

17. Primary Health Care Unit

18. Health Development Army(HDAs) Woreda , Zone Command Post • New initiative to expand best practices at large scale within short period of time • Enable the community to produce and sustain their own health through implementation of all HEP packages. • 1 to 5 networking is the main gear for the HDAs Health Center Kebele command post Dev’t Team Dev’t Team Dev’t Team 30 – 40 teams 1-5 1-5 1-5 1-5 1-5 1-5 1-5 1-5 1-5 1-5 1-5 1-5 1-5 1-5 1-5

19. Integrated Refresher Training • 21 days long refresher training to HEWs • Five components: ICCM, CMNCH, First AID, HIV/AIDS and TB and EPI • CMNCH- 10 days training • HEWs train HDAs using the IRT materials

20. Community HMIS • Master Family Index • Family Folder • Baseline from all households in a kebele • Includes the performance of each HEP package • Different cards which include different information on • Integrated maternal and child health care • HIV/AIDS and Tuberculosis • Growth Monitoring • Disease and referral information • Family planning and history of Immunization • Field book • Reporting formats • Monthly report from Health Post to Health Center

21. MaNHEP’s Experience

22. MaNHEP Experience • Recruitment and training of volunteers • Guide team • Quality Improvement Team • Responsibilities • Identification of pregnant mothers • Registration of pregnant mothers • Establish a family team • Conduct family meetings • Labor and birth notification • Provision of Misoprostol • Facilitate Referral

23. MaNHEP Family Meeting Topics

24. MaNHEP Experience… cont’d

28. MaNHEP Experience… cont’d

29. MaNHEP Experience… cont’d

30. CHALLENGES • Turnover of health workers • Competing priorities • Equipments and supplies • HEWs absent from their health posts • not notifying the HEW of labor and birth in the absence of maternal and newborn complications.

31. Lessons Learned • Government Commitment • Supportive policy environment • Evidence based interventions that are scalable • Use of data for Quality improvement

32. Can these help the country to improve coverage, and quality of services?...... Ans: In 2015 Thank you!