Save the Children® Save the Children MID-TERM EVALUATION REPORT Innovation for Scale: Enhancing Ethiopia's Health Extension Package in the Southern Nations and Nationalities People's Region (SNNPR) Shebedino and Lanfero Woredas Cooperative Agreement No.: GHS-A-00-07-00023 October 1, 2007-September 30, 2012 Category: Standard Submitted by: Save the Children Federation, Inc. 54 Wilton Road, Westport, CT 06880 Telephone: (203) 221-4000 - Fax: (203) 221-4056 Contact Persons: Eric Swedberg, Senior Director, Child Health and Nutrition Carmen Wedel', Associate Director, Department of Health and Nutrition Authored and edited by: Kate Gilroy, External Consultant; Save the Children US - Hailu Tesfaye, Awassa Sub Office Manager; Karen Z. Waltensperger, Afi:ica Regional Health Advisor; David Marsh, Senior Child Survival Advisor and CCM Team Leader; Cannen Wedel', Associate Director, Department of Health and Nutrition; Sharon Lake-Post, Senior Specialist, Communications. Submitted to USAID/GHIHIDN/CSHGP 31 October 2010 This report 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 Save the Children and do not necessarily reflect the views of us AID or the United States Government. ACT ANC ARl ASO AWD BoFED CCM CCMlP CDD C-IMNCI CMO CS CS-23 CSHGP CSTF DHO DIP DPO EPI EtCO FMOH GO-NOOs HC BFA HEP HEW HMIS HP HPC HR ICD IEC IFHP IMNCI IR ITN JSI kebele KPC ACRONYMS Artemisinin Combination Therapy Antenatal Care Acute Respiratory Infection A wassa Sub Office Acute Watery Diarrhea Bureau of Finance and Economic Development Community Case Management Community Case ManagementlPneumonia Control of Diarrheal Diseases Community-Integrated Management of Newborn and Childhood Illnesses Community Mobilization Officers Child Survival Child Survival-23 (USAID CSHGP 23rd cycle project) Child Survival and Health Grants Program Child Survival Task Force District Health Office Detailed Implementation Plan District Program Officer Expanded Program of Immunization Ethiopia -Country Office Federal Ministry of Health Government Organization- Non Government Organization Health Center Health Facility Assessment Health Extension Package Health Extension Worker Health Management Information System Health Post Health Program Coordinator Human Resource International Statistical Classification of Diseases Information Education Communication Integrated Family Health Program Integrated Management of Newborn and Childhood Illnesses Intermediate Result Insecticide Treated Bednets John Snow, Inc. Community/catchment area of approximately 5,000 inhabitants Knowledge, Practices and Coverage CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children ii M&E MNCH MOH MTE NGO NS ORS ORT OTP PNC PSI RDT RHB R-HFA SC SCD SNL-II SNNPR SS TA TAG TBAs TOT TTBA UNICEF US AID vCHW WHO woreda ZHD Monitoring and Evaluation Maternal Newborn and Child Health Ministry of Health Mid-term Evaluation Non-Governmental Organization Neonatal Sepsis Oral Rehydration Salt Oral Rehydration Therapy Outpatient Therapeutic Program Post-natal Care Population Services International Rapid Diagnostic Test Regional Health Bureau Rapid Health Facility Assessment Save the Children Federation, Inc. Safe and Clean Delivery Saving Newborn Lives-II Southern Nations Nationalities People's Region Supportive Supervision Technical Assistance Technical Advisory Group Traditional Birth Attendants Training of Trainers Trained Traditional Birth Attendants United Nations Children's Fund United State Agency for International Development Volunteer Community Health Workers W orId Health Organization District Zonal Health Department CS-23 Ethiopia, Mid-Tel1n Evaluation, October 2010 Save the Children iii TABLE OF CONTENTS SECTIONS A. B. C. D. E. F. G. H. Acronyms ........................................................................ . Executive SuInlnary ............................................................ . Overview ofthe Save the Children Child Survival - 23 Project. .......... . Data Quality: Strengths and Limitations ...................................... . Assessment of Progress Toward the Achievement of Project Results ... .. Discussion of Progress Toward Achieving Results ......................... . Potential for Sustained Outcomes, Contribution to Scale, Equity, Community Health Worker Models and Global Learning ................. . Conclusions and Recommendations .......................................... . Action Plan ...................................................................... . LIST OF ANNEXES Results Highlight List of Publications and Presentations Project Management Evaluation Wode Plan Table Rapid CATCH Table (not applicable) Mid-Term KPC Report (not applicable) CHW Training Matrix and URCfUSAID CHW AIM Evaluation Team Members and Titles Evaluation Assessment Methodology List of Persons Contacted and Interviewed Updated Project Data Form Special Reports (attached separately) Page 11 1 3 7 9 17 33 35 37 Annex 1 Annex 2 Annex 3 Annex 4 Annex 5 Annex 6 Annex 7 Annex 8 Annex 9 Annex 10 Annex 11 Annex 12 Annex 13 Almex 14 MTE Quantitative Results fi.-om Routine Monitoring and Rapid Assessment "Beta" Version of CCM Benchmark Indicators Applied to CS-23 in Ethiopia Annex 15 Action Plan CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children iv A. Executive Summary Background: Save the Children (SC) was awarded a five-year Standard USAID/CSHGP Child Survival Project (CS-23) -Innovationfor Scale: Enhancing Ethiopia's Health Extension Package in the Southern Nations and Nationalities People's Region (SNNP R) -to address four main causes of child death: (1) pneumonia, (2) malaria, (3) clianTIoeal diseases (that together account for 68% of under-five mortality); and (4) neonatal infection, responsible for half of all neonatal mortality. The proj ect is implemented in the SNNPR of Ethiopia, in the districts of Shebedino (Sidama Zone) and Lanfero (Silti Zone) and reaches 69,491 children 0-59 months of age; and 87,496 women of reproductive age. The overall goal ofthe project is to reduce childhood mortality, with a strategic objective to increase use of key childhood services and behaviors. The p~'oject focuses on the implementation of the three pillars of the Integrated Management of Neonatal and Childhood Illness (IMNCI) strategy in health centers (HCs) and health posts (HPs), including: 1) clinical IMNCI; 2) health systems support; and 3) community and family practices. Table 1 presents the intermediate results and activities in more detail. Main accomplishments at mid-term include: • Successful implementation of all pillars ofIMNCI, including; clinical IMNCI training of HC staff, and Health Extension Workers (HEWs) in HPs; provision of supervision and supplies for IMNCI; and training and support to volunteer community health workers (vCHWs) and others to improve family practices through community-IMNCI; • Increased access to IMNCI services and community promotion of family practices; • Introduction of zinc treatment for childhood diarrhea at HCs and HPs; and • Strong partnership and collaboration with local health authorities in the implementation of proj ect activities. Primary constraints include: 1) lack of continuous and sufficient supplies of essential medicines at HCs and HPs; 2) variability quality of supervision for IMNCI to HPs; 3) turn-over ofHC staff and HEP supervisors; 4) poor care seeldng for maternal and postnatal services and neonatal illnesses; and 5) routine monitoring systems in need of strengthening. Conclusions and key recommendations: Overall, the CS-23 project has successfully supported the implementation of the complete package ofIMNCI in facilities and the community. Its activities have and will serve as a model for implementation of comparable initiatives in Ethiopia and are on-track at mid-term. The grant to Save the Children from UNICEF to implement IMNCI in the community in 62 additional districts using a similar approach, is a good measure of the CS-23 project's success. The CS-23 project should now: 1) continue fostering strong palinerships with national and local health authorities; 2) strengthen implementation and routine monitoring; 3) improve utilization; 4) introduce pneumonia management in the community in light of the recent policy change; and 5) develop a transition plan to ensure sustainability after the close of the project. The CS-23 project should build on its success in introducing and supporting INMCI to develop, introduce and implement stronger strategies to improve neonatal health. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 1 T bl e 1 S a : ummaryo fM' aJor P . rOJec tA ccomp. l'h IS men t s Strategic Objective: Improved use of key child health services and behaviors Inputs Activities Outputs Outcome IR-l: Increased availabilitY and access to child health services and supplies 84% (103/121) of HEWs 14,700 U5s treated with IMNCI tr'aining Training of HEWs and HC tr'ained in IMNCI (1 HP per antimalarials annually (291 packages staff in IMNCI; 1000 U5s); malaria/fever cases treated per 90% (9/10) HCs with 1000 U5s); IMNCI trained staff; 10,346 U5s treated with IMNCI supplies >80% ofHPs with IMNCI antibiotics annually (205 (refenal slips, timer, supplies (except timer); pneumonia cases treated per chartbooks, registers) Provision of IMNCI supplies 1000 U5s); IMNCI drugs (ORS, and drugs to HCs and HPs 91 % ofHPs with zinc, 7,017 U5s treated with ORS zinc, ACTs, ABs, (initial & through supervision annually (1,927 with CQ) & logistics visits) 100% with ORS, 100% ORS+zinc) annually (139 support (transpOli, with chloroquine, 18% with diarrhea cases treated per 1000 petr'ol) ACTs on day of assess, visit U5s) IR-2: Improved quality of child health services In case scenm'io of pneumonia Transport, at 11 HPs: 100% of HEWs supervision 100% ofHEWslHPs report would classify & refer/treat tools/checklists, joint Supervision visits, provision supervision in previous correctly; 82% classify planning; Joint month; conectly & 9% reported full supervision of job aids assessment; 97% ofHPs meet FMOH Job aids to improve "functional" criteria 93% ofU5 cases at HPs with adherence to complete & consistent protocols classification & treatment recorded IR-3: Improved knowledge andacceptance of key child health services and behaviors c-IMN CI training 72% (108011500) of target Caretakers report lmowledge packages and IEC Training ofvCHWs and vCHWs trained; of key family practices & materials HEWs in c-IMNCI 68% (821121) of target illness danger signs * HEWs trained IR-4: Improved child health social and policy environment Key pminerships with Meetings, technical working health authorities at regional, zonal, groups, joint planning, Substantial engagement and buy-in for child smvival and district and local trainings and supervisions, IMNCI activities at all levels levels etc Techpical updates, Policy dialogue & advocacy policy briefs, forCCMIP; Pneumonia management at the community level now allowed publications, Participate in orientation, per FMOH policy, SC and other NGOs to implement in ~600 presentations (evidence & development & training for districts in 2010 feasibility of CCMIP) CCMIP at national level (' 10) *Focus group repOlts not representatIve and a convemence sample of caretakers chosen by HEWs and vCHWs CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 2 B. Save the Children Child Survival-23 Project in SNNPR, Ethiopia Nearly 400,000 Ethiopian children die each year before their:fifth birthdays. Save the Children (SC) was awarded a five-year Standard USAID/CSHGP Child Survival Project (CS-23) -Innovation/or Scale: Enhancing Ethiopia's Health Extension Package in the Southern Nations andNationalities People's Region (SNNP R) -to address four main causes of child death: (1) pneumonia, (2) malaria, (3) diarrhoeal diseases (that together account for 68% of under-five mortality); and (4) neonatal infection, responsible for half of all neonatal mortality. B1. Goal, Objectives and Results Figure 1: Save the Children, EthiopiaCS-n in SNNPR- Results Framework Figure 1 presents the results framework for the SC CS-23 project. The project Goal is "Under-five mortality reduced" and its Strategic Objective is "Use of key child health services and behaviors improved." The project has four Intermediate Results (IRs): IR-1: Access and availability of child health services and supplies increased; IR-2: Quality of child health I Goal: und8r.fwemortalfty reduced ' ' , I T ttrategiC Objective: UlIeofkey child hearth servicesl ' " and pracUces increased,' , , , , 1 , )R.3, ~ JR4, lR-1: JR·2: Acce'ss& Quality of Knowledge & ChUd: heatth avililablllty of child chHcI health acceptance of key socialand health services and services child health policy supplies increased improved services and environment ----- - ~- .- --- -- ,~~ .-.. -- .. ' [!!,actices improved enabled -- '===-~-~,~ ~-~-~,,~ Ol!erall implementation strategy: Community case management, capacity building, and behavior change atthehousehold level services increased; IR-3: Knowledge and acceptance of key child health services and behaviors increased; IR-4: Child health social and policy environment enabled. This framework serves as the basis for the project monitoring and evaluation (M&E) plan and this mid-term evaluation (MTE) repOli. B2. Project location and target popUlation This project is implemented in the SNNPR in the districts (woredas) ofShebedino (Sidama Zone) and Lanfero (Silti Zone). The project reaches a total population of366,898 in Shebedino (255,209) and Lanfero (111,689) districts, including 16,645 infants 0-11 months of age; 13,948 children 12-23 months of age; 40,815 children 24-59 months of age; 69,491 children 0-59 months of age; and 87,496 women of reproductive age. B3. Technical and Cross-cutting Interventions Technical interventions addressed in CS-23 include: Pneumonia case management (35%): Management of pneumonia with antibiotics at health centers (HCs), assessment and refenal at health posts (BPs) and promotion of early care-seeking; Advocacy at the regional and national level for inclusion of pneumonia management at health posts (HPs) within the Health Extension Program (HEP); CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 3 Control of Diarrheal Diseases (20%): Promotion of early care seeking, appropriate case management in home and at HP, introduction of zinc/ORS treatment protocol at HPs and HCs; Prevention and Treatment of Malaria (20%): Prevention through appropriate use of insecticide treated nets (ITNs), early care seeking, appropriate case management at HP, including rapid diagnostic tests (RDTs) and Artemisnin Combination Therapies (ACTs); Newborn Care (20%): Recognition of danger signs, biIih preparedness, promotion of use of antenatal care (ANC), delivery and postnatal (PNC) at HPs, HCs and in the community; Immunization (5%): Promotion of immunization through Health Extension Workers (HEWs) and volunteer community health workers (CHWs). Interventions integrated across the main technical areas include: III Capacity building, training and supervision for improved systems and provider performance; • Integrated management of neonatal and childhood illness (IMNCI) and strengthened Expanded Program of Immunization (EPI) in the community, at HPs and HCs; • Promotion of Health Extension Package for 16 key behaviors at the community and household levels delivered by HEWs and vCHWs; • Technical communication, policy dialogue and advocacy at the regional and national level for child survival activities, IMNCI, and pneumonia case management at the community level; III Monitoring and evaluation (M & E) of progress toward objectives in conjunction with local health systems, the local community and other key stakeholders. B4. Project Design The Ethiopian Federal MOH Health Extension Program (HEP) aims to achieve universal primary health care coverage. Health Extension Workers (HEWs) receive approximately one year of basic training and two HEWs are posted to a peripheral health post located in almost every kebele (a community/catchment area of approximately 5,000 habitants). Within the HEP, HEWs are responsible for both curative and preventative services. In each kebele, HEWs work with volunteer community health workers (vCHWs) in health promotion activities and in model household activities. In Lanfero and Shebedino districts, SC enhances the existing HEP system by implementing and supporting the three pillars of IMNCI, 1 in coordination with local health authorities. This is one 1 Clinical, health systems and community and family practice - see Gove, S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child, Sui WHO, 1997. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 4 of the first projects in Ethiopia to implement all three pillars? SC provided initial clinical IMNCI training to HEWs working in rural kebeles, including the diagnosis of malaria with RDTs and treatment with either ACTs (falciparum) or chloroquine (vivax), treatment of diarrhea with Oral Rehydration Salts (ORS) and zinc and the assessment of respiratory illness and referral for pneumonia. The IMNCI trainings for HC staff and HEWs had a high facilitator to pmiicipant ratio (1:4 for HC staff, 1:5 for HEWs); trainings used the Ethiopian adapted WHO IMCI training package which includes pmiicipatory teaching methods and 4-6 clinical practice sessions. To support clinical IMNCI, SC provided IMNCI registers, chart books, timers, referral slips and other supplies to all HCs and BPs. HC staff also received clinical IMNCI training, including treatment of pneumonia with antibiotics, andjob aids. SC staff, in coordination with the Regional Health Bureau (RHB) and District Health Offices (DHO), provide regular, ongoing support and supervision to health workers providing IMNCI clinical services. The Outpatient Therapeutic Program (OTP) to manage acute severe malnutrition was not integrated with IMNCI services. In 2010, SC worked with the DHOs to provide on-the-job training to HEWs in the integration of OTP and IMNCI services. In promoting community andfamily practices, HEWs coordinate with vCHWs in the communities to promote behavior change in use of available services and em'ly care seeking, immunization, growth promotion and appropriate feeding practices, hygiene and sanitation and home management of illness. The HEWs meet with vCHWs on a bi-monthly or monthly basis to coordinate activities. SC provided initial trainers' training in community-IMNCI to HEWs who then trained 1080 vCHWs. SC also provides ongoing support through community visits and supervision meetings. The vCBWs and HEWs received Information, Education and Communication (IE C) materials and counseling cards from CS-23 to support this work. Additionally, the CS-23 project coordinates with the RHB and DHOs to support preventive practices, such as distribution ofITNs, EPI and sanitation campaigns, etc. The SC CS-23 project promotes health sy,stems support for IMNCI services. In addition to providing ongoing support for supervision and training, SC also has assisted with supplies and drug stocks. These activities include working with the RHB and DHO to ensure adequate drug supplies and the purchase of ORS, ACTs and chloroquine for BPs and BCs when adequate stocks were not available. SC facilitated the introduction of zinc for diarrhea management in IMNCI algorithms in coordination with PSI. Lanfero and Shebedino m'e among the first in Ethiopia to pilot the introduction of zinc for diarrhea. 2 The Bolosso Sore Project in Wolayita Zone supported by USAID through the Integrated Family Health Program also implemented the three pillars of IMNCI in 2006 to 2008 [Implementing Integrated Management 0/ Neonatal and Childhood 1I1ness within the Health Extension Program, Bolosso Sore, SNNPR, Ethiopia. November 2009.] CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 5 In addition to the full implementation ofIMNCI, SC CS-23 conducted advocacy at the international, national and regional levels to promote child survival activities, with an emphasis on policy to include pneumonia management in the community (within HEWs' responsibilities) . Annex 4 presents the Mid-Term Evaluation (MTE) review of the project activities and achievements in relation to the Detailed Implementation Plan (DIP) work plan. There have been no significant changes in the program design, strategies, indicators, intervention mix, activities 01' location. BS. Partnerships and USAID mission collaboration The key partners of the project are collectively the local health authorities, including: 1) the SNNRP Regional Health Bureau (RJiB), especially the Family Health Department, the Child Health and Nutrition Team, the RHB HEP and Planning and Programming Department; 2) the Sidama and Silti Zone Health Departments; and 3) the Lalliero and Shebedino District Health Offices. These pminers have been involved since project start-up, through briefing meetings, the DIP workshop, the baseline Knowledge, Practices and Coverage (KPC) survey, a dissemination workshop, district-based planning and capacity building trainings for health professionals (facilitated by experts from the Federal Ministry of Health (FMOH), and integrated supportive supervision, as well as participating in the MTE. The key implementers of the IMNCI strategy are HEWs and vCHWs, which ensures local partnership and capacity building at the community level. SC also strengthens local partnerships by participating in the Regional Child Survival Task Force, the Technical Advisory Group (TAG) meetings and the EPI working group chaired by the RHB. In interviews conducted as part of the MTE, all RHB and government stakeholders cited the participatory nature of the project, highlighting the impOliance ofthe joint training, integrated supervision, joint meetings, and support for health systems (drugs, transport, etc). For example, one District Health Officer stated: "[We] work together for under-five children ..... Save the Children [staff] are lil" -=-:.c :;:: > '0 ):I '" '" Q,) <:.) <:.) < .-;' · E!i', Access to immunization: % of children age 12-23 months who received a DPT1 vaccination before they reached 12 months Clinical IMNCI coverage: % of HEWsNCHWs trained in llvlNCI Community IMNCI coverage: % ofHEWsNCHWs trained in c￾llvlNCI Availability o/zinc: % of health posts that report no stock out of zinc in previous month Docum￾entation¥ Docum￾entation¥ Docum￾entation;¥ Inventory of BPs 0% 0% 0% 60% 60% 75% posts; vaccination campaigns Training of HEWs in clinical llvlNCI Training ofHEWsNCHWs in c-llvlNCI Monitoring of stock and supply chain; trouble shooting; facilitation available at MTE, see indicator below for DPTIIPenta3 84% (1031122 HEWs trained in llvlNCI versus target HEWs - Lanfero= 37/50* Shebedino= 66/72*)** 68% (82/121 HEWs trained in c-llvlNClitarget HEWs)** 72% (108011500 vCHWs trained in c-llvlNClitarget vCHWs)** 64 % (7111 BPs with no zinc stock-out in previous 3 months - Lanfero= 3/7 Shebedino=O/4)** 91 % (10/11 BPs with zinc on the day of assessment visit) ** Progress: Almost full training of targeted HEWs; Gaps: Due to some target HEWs not yet introduced/deployed in urban areas* (or on leave) during training period and 5 HEWs transferred or left! died Progress: Almost full training of targeted vCHWs in 2008/9; Gaps: Due to govn't/MOH policy change to 1 vCHW per 20 HHs (increased number oftarget vCHWs), lower proportion of targeted vCHW strained; HEP policy now changed to 1:20 HHs Progress: Introduction of zinc in collaboration with PSI; Gaps: Drug supplies remain an ongoing challenge, as described in section E; Note: MrE indicator is longer period of stock-out than original indicator (therefore, 1 month stock out likely better then IR-J Notes: *Only 40 HEWs deployed in Lanfero and 69 in Shebedino atMTE, although targeted HEWs were higher; strategy of BPs /HEWs posted in urban kebeles recently introduced **More details available in text and Annex 13. ¥Documentation includes RHB/ZHDIDHO documentation and reports, project training records, stock out reports, etc CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 10 regarding inununization: % of posts; community vaccination vaccination per 1000 at BPs, RCs and outreach; children age 12-23 months who campaigns estimated births (proxy for Gaps: Some stock-outs of penta received a DPTI vaccination infants) annually in Q3 atRCs before they reached 12 months 2009 to Q22010(See Annex 13, Table 2 for more information & time-trend) Measles vaccination: % of KPC,2011 60% 75% Routine vaccination at health I No indicator of me asres- ] , I children age 12-23 months who EDRS posts; community vaccination available at MTE -e ,:;: received a measles vaccination campaigns regaJ:"dless of age 13-- .• til cu ·u Child with fever receives KPC,R-HFA, 17% 60% REWNCHW training in No specific indicator Progress: Promotion of °E 'CU appropriate anti-malarial: % of HF records IMNCIIc-IMNCI; BCl: REP available at MTE; 14,700 careseeking and services through ,til ..c children age 0-23 months with a review "16 packages", c-IMNCI children treated with c-IMNCI, routine activities & ..... "; febrile episode during the last two (model families, community antimalarial in 1 year campaigns weeks who were treated with an conversations, one-on-one period- See Annex 13, "'"' 0 effective anti-malarial drug within counseling in household) Tables 6-8 Gaps: High levels of stock-outs >. 24 hours after the fever began Only, approx 10-20% of of ACTs preclude prompt "; treatment and discourage ::I children receive prompt 0' careseeking M (within 24 hours off ever) e$ treatment as reported through routine systems (marked in register by BPIHC) Use of medicine during diarrhea: KPC,health 41% 22% REWNCHW training in No indicator of appropriate % of children 0-23 months with facility record IMNCIIc-IMNCL- BCL- REP HH diarrhea management diarrhea in the last two weeks review "16 packages", c-IMNCI available at MTE; few who were no treated with anti- (model families, community incorrectly treated diarrhea diarrheals or antibiotics conversations, one-on-one cases seen in register counseling in household) review ofRCs or BPs CS-23 Ethiopia, Mid-Term Evaluation, October 2010 11 Save the Children ., HEWperj"ormance: % of trained R-HFA, 0% 60% HEWNCHW training in In pneumonia case scenario Progress: Quality IMNCI training HEWs who followed correct observations, IMNCIIc-IMNCI; Supportive among 11 HEWslHPs: with close follow-up by IMNCI steps to assess, classify, supervisory supervision Assess Respiratory Rate: supervisors and staff; Gaps: treat, refer childhood illness records 82%** Supervision needs to focus more Full Assessment (danger on full danger sign assessment signs, chest indraw): and provision of timers 9%** Note: Case scenario a rough Classify: 100%** proxy for quality of services in Refer/treat: 100%** practice Functional supervisory system % R-HFA, 98% 100% Accompany, provide 100% received Progress: High frequency of of health posts that have received monthly transport, ensure check list supervision visit in last supervision by many actors; SC supportive supervision at least woreda supply and use, give feedback month** supports joint supervisions & once in past quarter (according to reports provides >50% of supervision MOH criteria) Gaps: Quality of supervision is variable & low motivation for HEP supervisors I Functional health system % of Documentatio 80% 90% Provide limited supplies, 97% ofHPs meet FMOH health posts meeting FMOH n¥ equipment, support, "functional" criteria (33/35 "functional" criteria facilitation HPs in Shebedino & 25/25 HPs in Lanfero) Functional health system % of R-HFA 54% 90% Remind, review, provide No indicator available at Progress: Standard IMNCI health posts that have met all feedback MTE registers provided by CS-23 and reporting requirements in past supported through trainings & quarter (according to MOH 93 % registers with supervision; Gaps: Sporadic criteria); % HEWs whose register complete/adequate and inconsistent reporting through records adequate information information * * govn't HMIS; no reporting of sick (age, dx, Rx) child management done in HHs .... ,-.., "w ... **More details available in text and Annex 13. ¥ Documentation includes RHB/ZHDIDHO documentation and reports, project training records, stock out CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 12 ,(I'J' . . ....... ell 'flo< -. '0 = ell- '" 8 .. '[ . . '" ..... "; ;.::: :9'. :a >" .. '0. =: . CI:I . ....... " C)" < '-] .. bJ) . ''0. ,., o . . =. ...... V e=- Matema[ danger signs: % of mothers who report knowledge of at least 2 maternal danger signs requiring immediate intervention Neonatal danger signs: % of mothers who report knowledge of at least 2 neonatal danger signs needing treatment Child danger signs: % of mothers who know at least 2 signs of illness in children needing treatment KPC KPC,2011 EDHS 29% 51% 60% 75% BCl: REP "16 packages", c￾IMNCI (model families, co=unity conversations, one-on-one counseling in household) BCl: HEP" IMNCI (model families, co=unity conversations, one-on-one counseling in HH) BCl: HEP "16 packages", c￾IMNCI (model families, co=unity conversations, one-on-one counseling in household) MTE lllUL""LU< available at MTE: Caretakers report some knowledge, but failure to seek care*** No indicator available at MTE, although mothers in focus groups report knowledge of key child illness danger signs*** , IR-3 Notes: ***Focus group reports not representative and a convenience sample of caretakers chosen by HEWs and vCHWs CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Gaps: Less program emphasis on maternal health, more on child and neonatal health Progress & Gaps: Despite knowledge, large challenges remain in "Acceptance" of careseeking for NN illness. Progress: Emphasis on promotion of careseeking and recognition of danger signs by vCHW s; Gaps: Relatively low utilization for sick children (Le. knowledge not translating to acceptance/ practice), esp in Shebedino (see below) 13 includes CCM as HEP strategy at I policy level of health post - including antibiotics for treatment pneumonia, dysentery, neonatal sepsis Facilitate policy dialogue, debate, technical updates; provide evidence offeasibility I pneumonia Progress: Advocacy by development partners, including SC, resulted in change of pneumonia policy in late 2009 Gaps: Neonatal sepsis mgmt delayed by SNL research delays 0; __ +-______ __ __ ____ __ ________________ __ g Joint planning for sllstainability: Documentatio NI AYes Participate in region, zonal, Yes Progress: Joint planning and .•. Joint planning takes place on n * district planning review meetings occurring in §;Q,l annual basis with collaboration with stakeholders . RHB/ZHDIDHO, SC, ESHE, and Gaps: None .. relevant key community ..;,;., , stakeholders IR-4 Notes: ¥ Documentation includes RHB/ZHDIDHO documentation and reports, project training records, stock out reports, etc ;C" - t; ".:' 'Q,li ;c ::= ::= u' .§ .. .;;... o. Q,l . '" 'l::l Appropriate hand washing practices: % of mothers of children 0-23m who live in a HH with soap or locally appropriate cleanser at the place for hand washing and who washed their hands with soap at least 2 of the appropriate times during the day or night before the interview KPC 28% 45% BCl: HEP "16 packages", c￾llvINCI (model families, community conversations, one-on-one counseling in household); HEWNCHW training in llvINCIIc-llvINCI No indicator available at MTE, although mothers in focus groups reported knowledge of key practices as, ;;.:. Increasedfeeding during KPC,2011 29% 43% BCl: HEP "16 packages", c- No indicator available at ii.;, diarrheal episode: % of children EDHS llvINCI (model families, MTE, although mothers in ;c, iQ,l ,0 ' aged 0-23 months with diarrhea in community conversations, focus groups reported the last two weeks who were one-on-one counseling in knowledge of key practices : :S.' offered the same amount or more household); HEWNCHW ,'..t:, food during the illness training in llvINCIIc-llvINCI CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 14 '" ,;.. d. Increasedfluid intake during diarrheal episode: % of children 0-23 months with diarrhea in the last two weeks who were offered more fluids during the illness HEP "16 packages", c￾IMNCI (model families, community conversations, one-on-one counseling in household); HEWNCHW training in IMNCIIc-IMNCI No indicator available at MTE, although mothers in focus groups reported knowledge of key practices ";: Appropriate care seeking for KPC,2011 32% 60% BCI: HEP "16 packages", c- No specific indicator Progress: Training for :@ , pneumonia: % of children age 0- EDHS IMNCI (model families, available at MTE; 10,346 appropriate treatment and referral , 23 months with chest-related community conversations, children with pneumonia at HC and HP; promotion of , ;s..: ' cough and fast and/ or difficult one-on-one counseling in treated in 1 year period careseeking ,":] breathing in the last two weeks household) HEWNCHW (155% of expected cases in Gaps: Low careseeking in ': who were taken to an appropriate training in IMNCIIc-IMNCI Lanfero; 15% of expected Shebedino :.@ health provider cases in Shebedino) - See ';;' , Annex 13, Tables 6-8** ,;,c:' , ;!::. , ';.c:: ';;.:, ,,:,::' ,"0, -""" -'" ? .. ' ..... .... """"J ..Q, o ORT use: % of children age 0-23 months with diarrhea in the last two weeks who received ORS and/or recommended home fluids. Zinc therapy: % of children 0-23 months with diarrhea in the last two weeks who were treated with zinc supplements KPC,2011 EDHS KPC,2011 EDHS, DHO/RHB service data CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 57% 72% 7% 25% BCl: HEP "16 packages", c￾IMNCI (model families, com. conversations, one-on-one counseling in HH); HEWNCHW training in IMNCIIc-IMNCI BCI: HEP "16 packages", c￾IMNCI (model families, community conversations, .one-on-one counseling in HH); HEWNCHW training in IMNCIIc-IMNCI; Dialogue, monitoring, trouble shooting, facilitation of zinc supply to health postsihealth centers No specific indicator available at MTE; 7,017 children treated with ORS in 1 year period (6% of expected cases in Lanfero; 1 % of expected cases in Shebedino) - See Annex 13, Tables 6-8** No specific indicator available at MTE; 1,927 children treated with ORS & zinc in 1 year period - See Annex l3, Tables 6- 8** Progress: Training for appropriate treatment and referral at He and HP; promotion of care seeking Gaps: Unclear from available information at MTE ifhome therapy is occurring Progress: Introduction of zinc at HCs & HPs; promotion of care seeking Gaps: Many fewer children with diarrhea treated with zinc than seen at HCs & HPs - Stock-outs a large challenge 15 '. .. f" ;c::, . ::: .. ,<:,: .'Q,l .. age 0-23 months who slept under an insecticide-treated bed (in malaria risk areas, where bed net use is effective) the previous night Post-natal visit to check on newborn within first 3 days after birth: % of children age 0-23 who received a post-natal visit from an appropriate trained health worker within three days after the birth of the youngest child KPC,2011 EDHS 4% 30% Bel: HEP "16 packages", c￾IMNCI (model families, community conversations, one-on-one counseling in household); HEWNCHW training in IMNCIIc-IMNCI Bel: HEP "16 packages", c￾IMNCI (model families, community conversations, one-on-one counseling in household); HEWNCHW training in IMNCIIc-IMNCI ;C:'., Immediate and exclusive KPC,2011 62% 69% Bel: HEP "16 packages", c- ;§: breastfeeding of newborns): % of EDHS IMNCI (model families, MIE No indicator available at MTE; HEWs & HCs report postnatal care, BUT not usually/always within 3 days :', newborns who were put to the community conversations, :]' .. ' breast within one hour of delivery one-on-one counseling in No indicator available at , ,,'0.' ,! and did not receive prelacteal HEWNCHW MTE; although caretakers $ ,: t feeds trammg m IMNCIIc-IMNCI in focus groups (not " . representative) reported Exclusive breastfeeding: (0-5 KPC,2011 3% 25% Bel: HEP "16 packages", c- .. b IYCF d . . . practicmg etter ue months): % of children age 0-5 EDHS IMNCI (model families, . al .. . . . . to promotion activIties months who were exclUSIvely commumty conversations, breastfed during the last 24 hours one-on-one counseling in SO Notes: **More details available in text and Annex 13. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children household); HEWNCHW training in IMNCIIc-IMNCI CS-23 project collaborated with on malaria campaigns giving logistics support and promotes preventive and treatment practices through HEP and vCHWs Progress: Some promotion of PNC; HEWs working with TEAs &vCHWs Gaps: Few assisted deliveries and late notification of births at home; No standardized birth notification and TEA coordination structure 16 E. Discussion of Progress Toward Achieving Results El. Contribution toward objectives-overall This section discusses the progress toward achieving the intermediate results (IR) and strategic objective (SO) as outlined in the results framework. Annex 13 presents additional detailed quantitative results, with key results presented in section D and discussed in the text. We discuss the remaining challenges and recommendations for potential strategies to overcome these challenges. E2. Contribution toward objectives- IRl: Access to services E2.a. Access to IMNCI services for sick children at HPs and HCs and c-IMNCI through vCHWs Overall access and referral: The project has achieved its targets for improving access to IMNCI services for sick children at HCs and HPs. All HCs in the two districts offer full IMNCI services and nine out of 10 have at least one IMNCI nurse on-staff, although turnover ofIMNCI-trained HC staff has been a challenge. Approximately 84% of the targeted HEWs are trained in IMNCI (management of malaria and dialThea, with referral of pneumonia), with approximately two HEWs trained in IMNCI (and one IMNCI functional HP) deployed for every 1000 children under five years of age.7 (see Annex 13, Table 1 for more details). National policy now permits the management of pneumonia in the community, with implementation scheduled to start in the third and fourth quarters of2010. Key stakeholders, local health authorities and project staff considered the IMNCI training for health center staff and HEWs, as well as the ongoing support to trained health workers, to be one of the most significant achievements of the project to date. Likewise, community members in focus groups also expressed appreciation for the availability of services through HPs: "HEWs and HPs benefit the community [through a variety of services] ...... they come near to us and our home-God bless them." A refelTal system is in place at each level in the community; vCHWs promote the use of HEWs and HPs and refer children to health posts using improvised refen-al slips provided by CS-23. At the next level, HEWs refer severely ill children or those with pneumonia to health centers using refelTal slips provided by SC. HEWs also refer children from HPs to HCs because of drug stock￾outs, especially CoArtem®, resulting in unnecessary refelTal. RefelTal from HCs to hospitals for severely ill children is a large challenge due to costs and transportation; there is no ambulance in either district. At the HP to HC level, families may refuse to accept refen'al due to fear of contamination and disease, as reported in MTE focus groups. Back refen-al from HCs to HPs posts happens infrequently and lack of feedback was reported to demoralize some HEWs. Challenges and recommendations: A small number of HEWs have left 01' transfelTed to other posts, and some HPs cun-ently have only one HEW. Additionally, the government of Ethiopia 7 Based on population estimates projected from 2007 census CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 17 has introduced health posts manned by HEWs in "urban"s kebeles, and these HEWs have not yet received initial IMNCI training. Although most HEWs deployed in Lanfero and Shebedino are trained in IMNCI, there is a need for the full complement of HEWs to receive initialIMNCI training in order to further expand IMNCI services. HEWs provide IMNCI services in the BPs, but many also reported treating sick children during house-to-house visits in the community. It was unclear how many curative services are provided in community by HEWs (in house-to-house visits) and if and how these treatment encounters are registered. Introducing more standardized tracking of sick children treated during household visits allow MOH and pminers to better track these encounters. Although the MTE did not observe or explore management of child illness given in house-to-house visits, standardizing this practice reported by some HEWs also might increase access and use of sick child services. Overcoming challenges linked to refenal is difficult; lack of resources within communities and in the health system is a large constraint. Save the Children should consider supporting more facilitation of referral by HEWs and health workers at HCs. Although all levels reported refenal of cases, albeit relatively low, they infrequently reported counseling or helping families complete the refenal process. In order to improve the system for refenal feedback, stalceholders suggested creating awareness (increase demand) in the community to ask for feedback slips at HCs, so that families can return feedback to HPs and vCHWs. Strengthening this system to give feedback on refenals could provide incentive to HEWs and vCHWs by demonstrating the importance of their work at higher levels. Additionally, the project should ensure that referral slips have feedback sections and that IMNCI refenal slips are available and used at all levels. E2.b. Availability of IMNCI supplies and drugs at Health Posts and Health Centres This section presents on the availability of supplies and drugs at HPs and HCs, drawing on the quantitative results of the rapid assessment (inventory) conducted during the MTE. Annex 13 includes the full quantitative results from the MTE assessment. MTE - Availability of Supplies: HPs in both districts were well equipped with most IMNCI equipment and supplies on the day of the assessment during the MTE, including IMNCI chartbooks and registers, refenal slips, thermometers, MUAC strips, scales, counseling cards and RDTs (Annex 13, Figure 1). Only half of the HPs visit had timers able to count seconds. Save the Children opted to provide 60-minute ldtchen timers due to the non-availability of UNICEF timers. One observed test of a ldtchen timer in Lanfero showed it to be ineffective because it did not "ring" after one minute, although others in Shebedino appeared functional. The timers' ability to measure 60 seconds precisely seems unlikely. Some HEWs relied on personal digital 8 "Urban" does not refer to cities or metropolitan areas, rather areas that are more densely populated and usually close to the district town. CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 18 watches or timers (precise to one second) in mobile phones. No BP had a functioning refrigerator on the day of observation. HCs were also well supplied (Annex 13, Figure 2) except for RDTs, which were present in only two of seven inventoried facilities. BCs reported use of microscopy for malaria diagnosis, thus stocks ofRDTs are not necessarily required. All BCs had functioning refrigerators. Although not formally assessed, most BPs and BCs appeared to have a functioning ORT comer. The general maintenance of some BP buildings, such as small rooms, lack of furniture and absence of clean water, negatively influences the functioning of these health posts. For example, some BPs visited did not have adequate conditions for drug storage and management. MTE - Availability of Drugs: On the day ofMTE visit, all HPs (100%) in both districts had ORS and chloroquine (Annex 13, Figure 3) and ten out of 11 BPs had zinc on the day of the visit. The availability of ORS at baseline (rapid BFA) was 73%,9 thus the MTE observed an improvement in ORS availability. During the MTE, CoArtem® was generally unavailable (present in only two of 11 health posts), and this was less available than at baseline (83% of health posts has 1 st line antimalarial at baseline). 3 BPs do not yet have cotrimoxizole for pneumonia management, since the change in national policy is so recent. Stock-outs in the last three months of chloroquine, zinc and CoArtem® were more common in Lanfero than in Shebedino (Annex 13, Figure 4). All HCs (100%) had ORS, zinc and cotrimoxazole on the day ofMTE visit, which is an improvement over the baseline rapid BFA. 9,10 There were gaps for chloroquine, pentavalent vaccine and especially CoAliem® (present in only four of seven facilities) (Annex 13, Figure 5). The availability of a first-line antimalarial drugs at BCs on the day of the visit was higher (76%) at baseline than during the MTE (57%).9 Stock-outs in the last three months were repOlted for all six items - all stock-outs were for 15 days or less except for CoArtem® in Lanfero, with average stock-outs of 30 days (Annex 13, Figure 6). Contribution of CS-23 project: Overall, almost all health posts and centers have adequate supplies to provide IMNCI services, as well as ORT corners, and this can be attributed to the CS￾23 project support and supervision activities. Key stalceholders and almost every service provider noted the provision and follow-up on supplies as a large contribution of the CS-23 project. But, all key informants from the regional level and zonal level to vCBWs and caretalcers in the community repOlied maintaining adequate drug supplies as one of the largest challenges to child health activities. The provision of kitchen timers without second hands occurred due to unavailability of UNICEF standard timers; UNICEF will provide standard UNICEF timers with the introduction of community-based pneumonia management in the 3rd or 4th qUalier of2010. 9 For more details, see: Save the Children/USA. Rapid Health Facility Assessment (R-FHA) Baseline Report, Lan/era and Shebedino Woredas, SNNPR, Ethiopia. April 2008. . 10 Baseline rapid HFA at Health Centers found 14% ORS availability, 86% Cotrim availability, 76% first-line antimalarial and no zinc available (not yet introduced). CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 19 Adequate supplies of zinc, chloroquine, and ORS were observed at HPs and HCs, with few reported stock-outs. Zinc has been introduced and supplied in coordination with PSI, with PSI providing zinc in-kind for pilot testing in the CS-23 districts. Using matching funds, the CS-23 project has supplied ORS, zinc, chloroquine and CoArtem®, as adequate drug supply through government health systems is an ongoing challenge in Lanfero and Shebedino Districts. However, private funds for drug supply will soon be depleted. Additionally, the SC project often provides supervision and logistical support, such as transportation resources, to ensure adequate drug supplies in peripheral health posts and health centers. The shortage of RDTs and CoArtem®, especially in Lanfero district, appears to be a combination of a large number of malaria cases in the district, alongside a weak stock management systems at the district, zonal and regional levels. Interviews with the FMOH and RHB revealed that stocks of CoAtiem® should be available at the regional level, but are not reaching districts for distribution to health service delivery points. Challenges and recommendations: Relatively weak stock management systems within government structUl'es and lack of drug supplies at all levels of the health system are ongoing challenges within the CS-23 project and threaten the sustainability of progress currently and at the completion ofthe project. Additionally, the shortage of transportation and petrol for activities within the government health system negatively impacts logistics and the provision of supplies to health posts and centers. The sustainability of zinc supply is also a large challenge; UNICEF and international bodies currently do not approve the only zinc supplier approved by the government of Ethiopia. Thus, currently all zinc must be procUl'ed through private channels. The project should work to strengthen the stock management system, including support for systematic monitoring of the drug stocks system at the HP and HC levels during integrated supervision and the introduction of stock control balance cards/sheets for health posts, which have recently been developed. For the life of the project, Save the Children should leverage additional private funds, to cover supplemental drug supplies.ll Greater coordination at the different levels ofMOH around drug supply, especially the regional level, may be needed to enSUl'e that drugs-especially CoArtem®-l'each districts and eventually health post. This coordination may need to involve in-kind contributions oftransportation resources to overcome logistical challenges within the government health system. The project in coordination with government health partners should rapidly assess the causes of the current CoArtem® shortages and stock-outs and potential solutions, especially in Lanfero district. In order to address further issues and challenges with stock and supplies, the project may consider coordination with Supply Chain for CCM (SC4CCM), a new JSI project implemented in Ethiopia and other countries, at the country and global levels. The project and its pminers need to develop a zinc supply transition plan to ensure the sustainability of zinc supplies for the remaining project period and after. 11 The recent grant from UNICEF for implementation of pneumonia management by HEWs (CCM/P) will cover some supplementary drugs in Shebedino. CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 20 E2.c. Access to (and use of) maternal and neonatal services at Health Posts and Health Centres Overall: Access to maternal and neonatal services within Lanfero and Shebedino Districts is more limited than for IMNCI services. All health centers provide ANC and delivery services, but very few health posts offer delivery services and only 10 HEWs (five in each district) had received training in Safe and Clean Delivery (SCD) at the time of the MTE. Due to delays in the Saving Newbom Lives (SNL) research on newborn sepsis management in Ethiopia, the sepsis management training for HEWs originally planned as pati of the CS-23 project will now not take place. Health center staff and HEWs have received basic essential newbom care training within IMNCI, but have not received training on management of the sick neonate or extensive training for essential newbom care. Women report using antenatal care (ANC) services at the health post and center levels, and promotion of these services is also reported at all levels. Promotion of assisted delivery at HCs was reported to occur at all levels-health centers, health posts (by HEWs) and in the community (by vCHWs). However, most women do not use assisted delivery at BPs and HCs. For example, in Shebedino routine service statistics show about 25 institutional deliveries per 1000 expected births from July 2009 to June 2010.12 A number of reasons for very low utilization rates were cited during the MTE. First and foremost, families cited home delivery as a more culturally appropriate practice, and mothers reported detesting the delivery Tables, as one HEW also noted: "Mothers hate the couch ..... God will help them deliver at home." Families cannot afford razors, gloves, towels and drugs, which is a balTier to delivery at health centers. F or example, one mother stated "we go to health facility [only] when labor is difficult ... especially due to lack of money and [because] the community does not support us to go." Messages about assisted delivery and newborn care almost exclusively target young women. Fathers and older women (grandmothers) often make key decisions about delivery and newbom care; however, they are not specifically targeted for key messages.13 HEWs deliver postnatal care (essential newborn care) in the community, but visits often happen many days after the biIih. Notification of the birth is often informal and late due to the overwhelming majority of deliveries in the home. For example, one HEW repOlied notification mostly through infOlmally encountering vCHWs or TBAs. Tracldng of post-natal visits within the routine HMIS does not differentiate timing of visit. Sick or healthy newborns are not brought to the HP or HC, and one HEW noted, "[Care is] not necessary for very young." Challenges and recommendations: The neonatal technical component of the CS-23 is the weakest in terms of progress; assisted delivery and careseeking for the newborn are abysmally 12 Routine service statistics on assisted deliveries at HCs were not readily available in Lanfero district or for previous periods in Shebedino. 13 All caretakers who come for care seeking irrespective of their age and sex are targeted at gatherings, at HPs, at church, etc, but no specific strategy has been implemented to reach fathers or grandmothers. CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 21 low due to a myriad of factors (see utilization section below), including cultural and health systems barriers. Management of sick newborns, essential newborn care and post-natal care messages are included for one day in the IMNCI training packages, although treatment of the sick newborn is not allowed at the health post level. There are gaps in the capacity of HEW s to deliver maternal and neonatal services in the community, and needs for training in Clean and Safe Delivery, Essential Newborn Care, Postnatal Care and counseling. The CS-23 project should leverage and advocate with other partners for Safe and Clean delivery tmining for HEWs. Because of the delay in SNL's sepsis management research, the CS-23 project should instead provide essential newbo1'1l care tmining using the postnatal visitation package from WHOIUNICEFISC. In order to promote assisted delivery and care for the newborn, the project should target messages and behavior change activities to fathel's and gmndmothers in addition to young women. The message that "every newborn is a human being with a right to survive" should be included in the package in order to promote use of services for newborns. The inclusion of more female volunteer CHWs, in addition to government chosen male volunteers, may assist in better delivery and targeting of messages and behavior change activities to promote assisted delivery and newborn care. Finally, the project should explore options and advocate with partners who could assist in the provision of clean delivery kits to families. E3. Contribution toward objectives- IR2: Quality of services In this section, we explore factors related to the quality of services, first describing the results from the MTE related to supervision and activities to improve quality of services and then we present results fl:om the MTE rapid assessment of quality of services. Within each section, we discuss the challenges and recommendations to improve health systems support and quality of services. E3.a. Supervision to ensure quality of services at Health Posts and Health Centres Supervision - overall: The CS-23 team and MOH partners identified supervision as a large challenge within the implementation ofIMNCI; therefore, we focused on supervision ofIMNCI services dming the MTE.14 The supervision of HEWs and HPs within the HEP system includes joint supervision from the DHO, from the HCs and weekly supervision by HEP supervisors. HEP supervisors are supervised monthly by the DHO HEP Coordinator. SC supports and joins many of these supervision visits, as well as SC staff conducting supervision visits. In fact, SC provides over 50% of supervision to HPs. The joint supervision with local health authorities was reported to be a large contribution of the CS-23 project, enabling high supervision completion rates at HC and HP levels. Key informants cite lack of transportation (old or no motorbikes) and resources for maintenance and petrol at the district and HC levels as major challenges to completing supervision. Additionally, government workers also have high worldoads that present challenges to completing scheduled joint supervisions. Supervision checklists are advantageous when used, and HEWs reported appreciating good supervision. One HEP supervisor summed up his 14 The information on supervision will also assist in further developing an operations research protocol. CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 22 experiences with SC: "We've good interaction especially in the training, supervision, provision of supplies and drugs, lEC materials. There are some improvement areas, like filling gaps when needed, and notifying of visits and schedules." MTE Results - Frequency and content o(Supervision: At the time of the MTE, HEWs at all Health HPs visited reported having received supervision in the last three months, many within the last week per HEP policy. HEWs reported that that content of the last supervision visit received at their HPs was good (Annex 13, Figure 7). Most HEWs from both districts reported that the supervisor checked records, corrected errors, and gave training (8 of 10). Likewise, most reported that the supervisor gave positive feedback, brought one or more supplies, and observed care (6-7 of 10). Observation of care of sick children was somewhat less common (5 of 10) perhaps because of the relatively uncommon occurrence of cases (see "utilization" below). However, few HEWs reported that the supervisor used a checklist (2 of 10). Supplying HEWs seemed better in Lanfero, while giving positive feedback seemed more common in Shebedino. Supervision reported as received at HCs over three months differed by district - with supervision in the last quarter at only two of four HCs visited in Lanfero versus at all of three Shebedino facilities. Informants at HCs reported that the content of the last supervision visit received at their facilities was also good (Annex 13, Figure 8). All parameters were reported to have occurred in at least four of five surveyed HCs, except bringing supplies, observation of care of sick children (3 of 5) and use of checldist (2 of 5, both in Lanfero). MTE - HEP Supervisors: During the MTE, we closely examined the responsibilities and challenges ofHEP Supervisors, as they are the primary support cadre to HEWs within the MOH's HEP system. 1S Lanfero and Shebedino Districts have experienced very high rates of turnover ofHEP supervisors. For example, in Lanfero District, of five HEP supervisors recruited and trained in 2008, only one remains. The HEP has deployed new HEP supervisors; these individuals have not received the standard two month HEP supervisor training for the 16 HEP packages or IMNCl training, although SC staff do provide "on-the-job" training for IMNCl and child survival activities. The "new" HEP supervisors only receive five days of training to serve as a supervisor for the entire HEP program. CU11'ent HEP supervisors stated during MTE interviews that the work is tiring and hard, especially due to lack of transportation resources; they are expected to walle to each HP in their catchment areas (on average 1-7km) every week. HEP supervisors' salaries are lower than similar cadres in other sectors (such as education or agriculture), and key informants noted HEP supervisors lack the opportunity to "top-up" their salary through supplemental work, such as clinical nurses who are paid for night duty. Two of the four HEP supervisors stated they needed at least enough money to "buy food." One HEP supervisor in Lanfero summed up his experiences: "[1 am a HEP supervisor to] talee part in main disease problems that can be solved .... but, 1 would go elsewhere for more money or to a more comfortable area than if that 15 There is a recent initiative to strengthen the Primary Health Care unit (comprised of lHC and SHPs), as a consequence the HC will be responsible for all HPs under it, rather than relying solely on the HEP supervisor for HEW supervision. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 23 opportunity came." All these factors, as well as remote po stings, lead to low motivation ofHEP supervisors and high turnover rates. Despite the challenges ofHEP supervisor motivation which appeared to influence performance, we also encountered high perfOlming HEP supervisors. A "positive deviant" HEP supervisor in Lanfero district who received only the minimal (5 day) training had a good plan. and good completion of his plan. Additionally, he reported sharing best practices among HPs and developing criteria for "competition" among HPs in order to motivate the HEWs. Challenges and recommendations: Supervision frequency is high at BPs; however challenges remain with the quality and sustainability of supervision, as well as HEP supervisor motivation. Supervision plans, documents and tools are often not reliably available at Health Centers and supervision checklists are not consistently used at any level. HEP and DHO supervision checklists cUTI'ently do not include all IMNCI components. Save the Children has adapted and shared an II\1NCI checklist with regional health authorities and the checldist is cUTI'ently under review. The very high frequency of supervision, often with variable quality, within the MOH system, raises concerns over the sustainability of this approach and the balance between quantity and quality of supervision. The challenges ofHEP turnover and motivation, as well as transportation constraints, discussed above, invariably contribute to the challenges and variable quality of supervision. Additionally, frequent supportive supervision by SC staffhas contributed greatly to the CS-23 project objectives, but also raises concerns over sustainability at the close of project. Save the Children should provide initial or }'ejJ'esheJ' tJ'aining in IMNCI and II\1NCI supervision (checldists) for HEP supervisors and other staff involved in supervision, with preference given to recently recruited HEP supervisors.16 Save the Children may consider initiating discussions with the RHB and other health authorities about the initial, two month HEP supervisor training CUTI'iculum, length, etc. and the potential of alternative, lower cost options to the two-month in￾residence trainings. Once approved by the RHB, CS-23 should provide IMNCI supeJ'vision checfclists16 to the HEP supervisors and other supervisory staff, with SC staff providing on-the￾job training through joint supervision visits. Planning for joint supervision visits with opportunities for on-the-job training could be strengthened. 17 The high frequency of variable quality supervision and the less than adequate incentive structure for HEP supervisors are institutionalized within the government's HEP system; thus, these challenges are difficult for the CS-23 project to address. The project may consider ongoing advocacy and discussions at the national and regional level to test alternative supervision approaches. 16 The new IMNCl/iCCM training will incorporate a one-day training with practical session for HEP supervisors on supervision of HEWs in IMNCI/iCCM. The associated checklist is already developed and agreed for use. 17 Other alternatives for on-the-job training could be considered, such as filming a role play of a high-quality supervision visit that could be shown locally to HEP supervisors and program managers. CS-23 Ethiopia, Mid-TelTIl Evaluation, October 2010 Save the Children 24 Most traditional incentives to motivate HEP supervisor have large budget implications (e.g., salary, per diems, cash incentives, refresher training) and are outside the scope of the CS-23 project or may not be feasible within the HEP system. However, low cost incentives, such as celiificates, recognition or small awards (such as phone credits) for high performing HEP supervisors could recognize their work. 18 The CS-23 project has started development of an operational research proposal to address supervision challenges, including the motivation of HEP supervisors. This operational research proposal should be finalized and implemented in coordination with national, regional and local health offices. Finally, in the next phase, Save the Children should work with the MOH partners to develop a transition plaon for supervision of health posts and health centers in IMNCI. E3.b. Quality of services at Health Posts and Health Centres WE - Quality of Case Management: MTE team members administered a structured case scenario to providers in order to assess reported management of a "six-month old infant brought for cough and difficult breathing." Although HEWs do not treat pneumonia, they have been trained to assess acute respiratory infections (ARl) and refer children with fast breathing or danger signs. The reported case management of HEWs at BPs was spotty, with few checking for general danger signs, chest indrawing or duration of cough (Annex 13, Figure 9). Most HEWs reported they would check the respiratory rate, but not all ofthese had the equipment to do so. When informed that the infant's respiratory rate was, in fact, 55 breaths per minute, all HEWs conectly classified the child as having fast breathing or pneumonia and opted for referral. Thus, complete assessment (all the steps of which are specified in the IMNCI Register) was poor, but classification - when provided the respiratory rate - and response (Le., referral for treatment) were perfect (Annex l3, Figure 10). Overall, Shebedino HEWs seemed to perform a bit better than their Lanfero counterpalis. Reported case management atBCs was good (Annex l3, Figure 11). The main gaps -less commonly observed than at HPs - were checldng for general danger signs, chest indrawing or duration of cough. As observed among HEWs, assessment was not strong, but classification and treatment were perfect (Annex l3, Figure 12). Again, Shebedino HC staff may have slightly out￾performed their Lanfero counterpmis. Quality of Case Management Recording: The MTE members also reviewed selected details from the IMNCI Registers for the last 10 sick children under age five years of age to assess both the completeness of recording and the consistency between recorded classification and treatment. Recording in each district was slightly better at BPs than at BCs (93 vs. 87% complete and consistent) - although both were high (Annex l3, Figure l3). Levels were similar between the districts. This indicator, though easy to obtain, is at best an indirect measure of quality because￾among other factors - the unverifiable validity of what is recorded. 18 Similar to those examined in for vCHWs in: Amare, Y. Non-Financial Incentives for Voluntary Community Health Workers: A Qualitative Study. Addis Ababa: JSI Research & Training Institute, Inc. 2010. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 25 Challenges and recommendations: The quality observed through our rapid assessment was relatively good. However, project staff and MOH partners reported gaps in capacity of HEWs and the need for IMNCI refresher training, with emphasis on assessment of danger signs. With the new FMOH policy allowing management of pneumonia with antibiotics in the community, the HEWs should be trained in the treatment of pneumonia with antibiotics as soon as possible. This training has already commenced with funding from UNICEF in some areas, and it may present an opportunity to refi'esh HEWs skills in other IMNCI and c-IMNCI components. E4. Contribution toward objectives- IR3: Knowledge of key services and practices Overall: The project activities to promote the lmowledge of key services and practices are progressing as planned. The CS-23 project has trained HEWs and 1080 vCHWs in c-IMNCI and provided job aids and counseling cards to support their activities; c-IMNCI refresher training was provided to 831 vCHWs in 2009 (see Annex 13, Table 1 for more details). Additionally, the CS-23 project conducted community sensitization activities before c-IMNCI trainings and provides ongoing supervision to HEWs and vCHW s in c-IMNCI. Save the Children recently (March 2010) recruited two community mobilization officers (CMOs) to support the community work in each district (Annex 3) and to allow for more intensive follow-up of c-IMNCI activities in communities. vCHWs are using job aids to promote family practices in communities and there appears to be strong relationships between HEWs and vCHW s in their work. Communities report appreciating the work of the HEWs and vCHWs. During the MTE, mothers in focus groups reported lmowledge of appropriate behaviors about early careseeking for childhood illnesses, use ofITNs, infant feeding, etc., and they report changing practices; however, due to cultural factors care for mothers during delivery and newborns remains a challenge. Community-based workers (HEWs and vCHWs) reported being relatively motivated in their work; the community appreciates them and workers report changes in practices and outcomes that motivate them. However, vCHWs did ask for refresher trainings and in-kind incentives, such as boots, bags, etc. Challenges and recommendations: The government structure dictates one vCHW per 30-40 households or approximately 25 vCHWs per health post. Thus, some vCHWs under this structure remain untrained in c-IMNCI (e.g. in Lanfero 249 vCHWs trained, out of625 CUll'ent vCHWs). The new vCHWs should receive initial training in c-IMNCI. Existing vCHWs should receive a short refresher training in c-IMNCI, both to reinforce skills and to incentivize their work in the community. 19 19 The refresher training recognizes their work formally with the health system and also provides small allowances that serve as an incentive. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 26 Although vCHWs repOli relative job satisfaction and intrinsic motivation to continue their services, some incentives for vCHWs needs to be institutionalized in the CS-23 project to ensure quality and sustainability over the life of the project. Giving certificates to well-performing vCHWs would be close to cost-neutral and could more formally recognize vCHWs' work in their communities. Additionally, local health authorities agreed that awarding certificates would be feasible; such low resource incentives could also be continued after the close of CS-23. Local radio spots, where well-performing vCHWs were interviewed about their work, could serve as both a motivator for vCHWs and an additional channel of communication for promotion of key family practices. Save the Children should also consider giving vCHWs small in-kind incentives-such as t-shirts, calculators, or bags-to recognize and help with their work. Ongoing SC initiatives, such as Ethiopia's EveryOne campaign, could potentially provide the in￾kind incentives with few costs to the CS-23 project. Ideally, the CS-23 project and local health authorities should define apackage of incentives for vCHWs over time that includes some of the above, and perhaps other feasible, locally appropriate incentives to recognize the vCHWs' work. A recent study conducted by JSI exploring motivation and provision of non-financial incentives among vCHWs in Ethiopia and the role of institutions in sustainability of the approach, recommends a similar strategy: a mixture of recognition in their communities, non-financial incentives, and sufficient support from the health system (e.g. mentoring, training and advancement oppOliunities).2o The promotion and community acceptance of key practices related to the perinatal period (ANC, assisted delivery and newbom care), remain one of the largest challenges within the CS-23 project. As noted above under access, promotional activities target young women, although fathers and grandmothers may be the main decision makers in households. The project should explore how to better target the decision-makers in households with appropriate messages about careseeldng, assisted delivery, and newbom care. Additionally, far less than half (37%) of the government selected, c-IMNCI-trained vCHWs are female (684 male; 396 female) and it may be more difficult for male volunteers to convey messages about appropriate practices in the perinatal period. The HEWs and communities primarily selected vCHWs and the gender gap cannot be remedied easily within the existing structures. However, the project should consider the recruitment and support to supplementalfemale vCHWs, who perhaps would concentrate on key matemal and neonatal health messages. Additionally, GOAL-Ethiopia's experience with mother-to-mothers group may be a promising strategy to promote these key practices. CS-23 should collaborate with GOAL to explore the feasibility and development of the mothers' group strategy to promote key practices in the perinatal period. Although this strategy is resource intensive, it could be tested for feasibility in a few kebeles; the newly recruited CMOs could facilitate the groups. 20 Amare, Y. Non-Financial Incentives for Voluntary Community Health Workers: A Qualitative Study. Addis Ababa: JSI Research & Training Institute, Inc. 2010. CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 27 ES. Contribution toward objectives- IR4: Policy Environment SC has engaged in policy dialogue and advocacy at the international, national and regionaVlocal levels in order to foster a positive policy environment. International level: At the international level, SC advocates for child survival programming and best practices. Health workers from Shebedino and the CS-23 project team are featured in a US￾based campaign for child and neonatal survival sponsored by the Ad Council that aims to garner support and funding for MNCH services. An Italian donor group visited the project in 2010, and based on this successful mission will support Ethiopia's EveryOne Campaign. 21 National level: SC is a member of the National Child Survival and CCM Task Forces, and has presented experiences from CS-23 and other related projects at the regional, national and international levels (Annex 2). Much of this advocacy has focused on fostering policy change to permit management of pneumonia with antibiotics at the community (HEW) level. In late 2009, the government of Ethiopia changed the HEP policy to allow pneumonia management with antibiotics in the community. This achievement in the policy environment was likely influenced, in combination with political and contextual factors, by a myriad of advocacy activities by many development partners, including SC's. IMNCI at the HP level (CCM), including treatment of pneumonia, will be introduced at-scale in Ethiopia through support from UNICEF. SC has been awarded a grant from UNICEF-Ethiopia to implement IMNCI with pneumonia treatment in 62 districts in the Oromia and SNNP regions, including Shebedino district. Regional and local level: Save the Children has a strong partnership with the regional and local health authorities and frequently cruTies out joint supervision and collaborative planning and review meetings. These activities likely influence the prioritization of child survival activities in the region and districts-as one. The recent mid-term review of the CS-23 project conducted by the BoFED and RHB found that collaboration and pruinership with the DHOs suppOlis efficient resource use, and contributes to the success of the program. 22 Additionally, Save the Children participates on the Regional Child Survival Task Force and facilitated the fonnation of district-level Child Survival Task Forces. Save the Children pruiicipates in related regional and local task forces, such as the EPI technical suppOli group, as 21 EveryOne is Save the Children's new five-year global campaign to reduce child and maternal mortality in 36 program countries, with a goal that the Millennium Development Goal4 is achieved and five million children will have been saved. In order to achieve its vision that within five years, no child dies from preventable causes and that public attitudes will not tolerate a return to high levels of child and maternal deaths, it employs four integrated campaign strategies: 1) Programmes; 2) Popular mobilization; 3) Political and policy changes; and 4) Resource mobilization. [http://www.savethechiidren.net/aliiance/what_we_do/everLone/index.html. accessed Sept 30th, 2010] 22 SNNPR, Regional Health Bureau. Mid-term evaluation for: Enhancing Ethiopia's Health Service Extension Program in the Southern Nations and Nationalities People's Region (SNNPR), Save the Children Child Survival Project. June 2010. CS-23 Ethiopia, Mid-Te1m Evaluation, October 2010 Save the Children 28 well as assisting the regional and local health offices with child survival related emergencies and activities, such as illness outbreaks and malaria campaigns (see Annex 12 for the report from the Acute Watery Diarrhea Outbreak activities). E6. Contribution toward objectives-Strategic Objective: Use of services Although use of services is best measured in relation to the population in need (i.e., coverage estimates through a population-based survey as indicated in the M & E matrix), we present utilization and treatment ratios compiled from routine monitoring data and register extractions during the MTE as proxy measures of coverage. Overall Utilization o[Curative Services: Annex 13, Table 3 presents the overall utilization of sick child services at health posts and centers as collected through CS-23 routine service monitoring. Almost 6,000 children were seen at BPs in Lanfero over a one-year period, while less than 2,000 were seen at HPs in Shebedino, despite almost double the population. Average visits per HP per month also exhibit this differential; on average HPs in Shebedino saw five children per month from mid-2009 to mid-2010, while HPs in Lanfero saw an average of 20 children per month (Annex 13, Table 3). The register extraction for the period of April to June 2010 observed more sick child visits per HP per month in Shebedino (on average 13 visit per HP per month) than for the yearly period (on average 5 visits per HP per month),23 with similar workloads observed in Lanfero (average of 19 cases per HP per month) (Annex 13, Tables 3-4). Average visits per month (worldoads) were similar among HPs visited in Shebedino (mean 13 with a range from 10 to 17), while HPs in Lanfero ranged from three to 39 sick child visits per month at different HPs (mean=19 sick child visits at HP per month). HEWs in Lanfero HPs recorded treating more sick children in the month of June than those from Shebedino (Annex 13, Table 4). There were no important sex differences among cases; however, no HEW in either district recorded treating an infant less than age two months. Annex 13, Table 4 shows the case mix in each district; Lanfero had more presumed malaria ("fever"). Many HPs treated many cases of acute malnutrition; however, the data collection tool was not designed to tally this; therefore, these were included in the "other" category. AtBCs the same differential in utilization was present. Over 31,000 children were seen at HCs in Lanfero over a one-year period, with only 4,300 seen in Shebedino HCs (Annex 13, Table 3). Similarly, the average number of visits per HC per month were over ten times fewer in Shebedino in this one year period (average of 60 sick child visits per HC per month) than in Lanfero (763 visits per HC per month). Register extractions from the MTE showed similar trends (Annex 13, Table 5). This differential in utilization between the two districts was also observed at baseline.24 Lanfero HCs treated more males than females (mean: 431 vs. 331) 23 This discrepancy may be due to the quality of data available through the routine systems-e.g. yearly estimates of average utilization per HP per month are less due to missing data, or could be due to seasonally fluctuations in the incidence of child illness. 24 For more details, see: Save the Children/USA. Rapid Health Facility Assessment (R-FHA) Baseline Report, Lan/era and Shebedino Woredas, SNNPR, Ethiopia. April 2008. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 29 compared to Shebedino (mean: 51 males and 50 females). Young infants under two months of age were uncommonly treated: only 3 in Shebedino and 31 in Lanfero, nearly all of whom (30) were male. The case-mix was similar in both districts (Annex 13, Table 5). Child treatment and treatment ratios for each IMNCI illness: Annex 13, Tables 6 to 8 present the number of child treatments and the treatment ratios by district over the last Ethiopian calendar year?5 Shebedino District reported 1,434 cases of pneumonia treated with antibiotics, 2,293 children treated for clinical (presumptive) or RDT + malaria and 1,520 children treated with ORS for diarrhea (544 with both ORS and zinc) over the one-year period. In Lanfero, the majority of children seeldng services were treated for malaria (12,407 children treated), likely due to malaria outbreaks in the district. However, a large number of children were also treated with antibiotics for pneumonia (8,912 cases) and ORS for diarrhea (5,497 cases). In relation to the population of children under five years of age, Lanfero treated almost ten times more cases of pneumonia than Shebedino (465 cases treated per 1000 estimated population of under-fives in Lanfero versus 45.7 cases per 1000 estimated population of under-fives in Shebedino). The trend was similar for malaria cases treated, whereas Lanfero treated five times more cases of diarrhea with ORS than Shebedino in relation to its population of under-fives (Annex 13, Tables 6 and 7). Trends in the utilization of sick child services and provision of treatments are difficult to interpret given the limited availability of estimates prior to the third quarter of2009 - due to seasonality, annual estimates are needed for interpretation. The last column of Annex 13, Tables 6,7 and 8 present "treatment ratios," which in simple terms is the ratio of the number of reported cases treated per the number of cases expected given the estimated incidence of illness and population of children under-five over a one year period. This measure can give a general idea about the coverage of services among the population needing the services, but it also must be interpreted cautiously given the use of service statistics and very rough estimates of illness incidence and catchment area population. In Shebedino, approximately 15% of expected pneumonia cases were treated with antibiotics; 7% of expected malaria cases and 1 % of expected dia11'hea were treated at health centers and posts. The observed results from Lanfero were more impressive, with 155% of expected pneumonia cases treated, 65% of expected malaria cases treated and 6% of diarrhea cases treated at health centers or posts (Annex 13, Tables 6 and 7). Interpretation and recommendations: Sick child services (for children 2-59 months), especially for pneumonia and malaria, appear to be reaching a significant proportion of the children in Lanfero district. The lower rates of care for diarrhea in Lanfero and Shebedino may be due to home management of the maj ority of simple episodes of diarrhea. Although illness incidence is likely higher in Lanfero, we found in all assessment methods that utilization of sick child services in Shebedino was considerably lower at both HCs and HPs, despite a much larger population. Key informants noted that the CS-23 team had explored the causes of low use of 2S From July ?009 to June 2010 CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 30 services in Shebedino but have not been able to identify contextual factors-such as a larger private sector or long distances to facilities-that would account for the low utilization ofHCs and HPs. In addition to continuing the implementation of IMNCI at all levels and promoting higher utilization of HPs, the CS-23 project should further explore and document the causes of low utilization in Shebedino in order to address these issues through project implementation. The utilization of services preferentially for male children in Lanfero is addressed below under "equity. " Very few cases of neonatal illness were seen at HCs and almost none were seen at HPs. This evidence of appallingly low careseeking for newborns is likely related to low rates of assisted delivery and lack of awareness that health services are available for newborns (discussed above). In addition to the recommendations outlined above, such as further training in essential newborn care and safe delivery and targeted health promotion activities, the CS-23 project should draw on lessons from the SNL research as well as consider a rapid assessment to explore and address low rates of care seeking for neonatal illnesses. E7. Contextual Factors Contextual factors influence the implementation, sustainability and potential impact of the CS-23 project. Many of the implementation-related contextual {actors have been discussed above. For example, weak health systems for HMIS and drug supply within the government structures challenge IMNCI implementation. The chronic lack of logistical resources for support activities-e.g., neither of the DHOs has a vehicle and there were only 1-2 old motorbikes for all their activities and petrol is often not included in the operating budget-threaten the sustainability of progress at the close of the project, constrain the day-to-day functioning of DHOs and challenge the CS-23 proj ect coordination with MOH partners. Health staff in both districts have many competing demands on their time; with many staff absent from their posts to engage in other, sometimes non-health related activities. Additionally, the new Business Process Reengineering is a relatively new government initiative that aims to improve the accountability of government services. 26 The restructuring of health system management and services at the health center level and lower has the potential to support or impede delivery ofMNCH services. Positive and negative impact-related contextual {actors are also present. Positive synergies with other projects are present in Shebedino district, where local NGOs support maternal and neonatal health programming. Lanfero has few complementary health projects. The recent policy change to allow pneumonia management in the community is promising; however, the previous policy precluding the use of antibiotics in the community delayed the introduction of this important intervention in the project areas. Current policy does not allow neonatal sepsis management at 26 Oebela, T. Business process reengineering in Ethiopian public organizations: the relationship between theory and practice. JBAS, Vol.l No.2 Sept. 2009. (accessed from http://ajol.info/index.php/jbas/article/viewFile/57348/45731, 2 nd October 2010) CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children ' 31 the HEW level. The delay in the community management of pneumonia policy change and continued dialogue on HEW sepsis management could negatively influence the potential impact of the project. Low utilization for sick child services at HPs and HCs-especially in Shebedino-constrains the potential impact of IMNCI implementation, even if services are available and provided at high quality?7 The high levels of acute malnutrition in the CS-23 project areas, especially Lanfero, and the integration of the IMNCI curative package with OTP visits (the Ethiopian government program to manage acute severe malnutrition) increase the likelihood of an impact of the CS-23 project strategies. E8. Role of Key Partners As discussed above, the MOH at all levels is the main partner in project implementation. Other PVOs and multi-lateral agencies are also partners; the role of each partner in the project, results of the collaboration and suggestions for improvements are presented in Table 3. Table 3. CS-23 Ethiopia Key Partners Partners I Role in Project Result of Overall Collaboration Activities/ Suggestions for Improvements Regional Health • Approval and support for CS-23 Results: Bureau activities, particularly with HEWs and • Activities for building the capacity of HEWs and communities. vCHW s have proceeded as planned; and • Participate in j oint planning and • Introduction ofIMNCI supports and strategies progress review; have proceeded as planned; Zonal Health • Lead and participate in CS Task Force • High level of buy-in for IMNCI and child survival Offices and TAG meetings; activities and • Participate in training activities and provide follow-up on service provision Suggestions for improvements: Lanfero and after training; • Increase coordination and frequency of joint • Conduct joint supportive supervision supportive supervision suggested; Shebedino of HEWs periodically; • Increase coordination on monitoring data and use District Health • Ensure that Health Posts have essential of HMIS systems for child survival interventions; Offices supplies and medicines for maternal • Develop jointly a transition plan for the end of and child health; project • Appropriate dish'ibution to Health Posts within the target area of any equipment donated andlor essential medicines; Population • Provide orientation training for zinc • Introduction of zinc has proceeded as planned; no Services h'eatment and provide initial stocks of suggestions for improvement International in zinc. Ethiopia GOAL-Ethiopia • Provide assistance for orientation • GOAL staff have readily collaborated with SC, training for zinc treatment; CS-23, sharing available information and • Collaborate in sharing plans and experiences. results for child survival programming. 27 Bryce J, Victora CG, Habicht JP, et al. Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness. Health Policy Plan 2005;20 Suppll:i5-i17. CS-23 Ethiopia, Mid-Telm Evaluation, October 20 10 Save the Children 32 E9. Overall design factors that are influencing progress toward results The CS-23 project's choice to implement simultaneously all three components ofIMNCI (clinical, community and health systems) at HCs and HPsfor one of the first times in Ethiopia is commendable. This design serves as a model for future programming in caring for the sick child in the community in Ethiopia and beyond. This design is considered best practice to achieve results in improving access and utilization of sick child services,28 although it is rarely implemented in practice. The newbom care technical component has received less attention in design and implementation. The CS-23 project planned to train HEWs in management of sepsis and neonatal infections based on results and lessons learnt in an SNL-funded randomized control trial to be carried out in SNNPR and Oromia, but this activity has been delayed and now does not expect findings within the life ofCS-23. Because of this delay and the need for stronger emphasis on the neonate in order to achieve the CS-23's ultimate goal ofimpacts on under-five mortality, the project will need to re-work the original design and strategy for improving neonatal health, perhaps strengthening postnatal visitation, recognition of danger signs, and referral. F. Potential for Sustained Outcomes, Contribution to Scale, Equity, Community Health Worker Models & Global Learning Fl. Progress toward Sustained Outcomes The SC CS-23 project has fostered sustained outcomes primarily by worldng closely with national and local health authorities. Although sustainability may be a challenge due to limited logistical resources for health systems supports such as drug supply and transport for supervision, the CS-23 project has contributed to the prioritization of child survival-related issues and programming within the routine government systems in Lanfero and Shebedino Districts. Likewise, because the CS-23 project built on the existing HEP system, providing additional support to this existing government strategy, the project activities will continue beyond the close of the project. Because of the insistence of government authorities that HEWs do not handle money, no effOlis of cost-recovery or community-based financing are feasible at this time. SC has secured other funding to continue the strategies developed under the current cooperative agreement. UNICEF granted the Ethiopia Country Office (EtCO) almost three million US dollars to implement community-based IMNCI (CCM) in Shebedino and 61 additional districts in Oromia and SNNP regions over the next three years. SC-Italy has awarded a grant of four million US dollars to continue similar work in Konso and Derashe Special Districts of SNNPR. 28 Clinical, health systems and community and family practice - see Gove, S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child, Bul WHO, 1997. CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 33 In the next phase of SC's CCM initiative, staff should work with government and other PVO partners to develop a phase-out plan to ensure the sustainability of project. F2. Contribution to replication or scale-up The CS-23 project has been an example for Ethiopia in that it has implemented all three pillars of the IMNCI strategy at the HP level. The strategy implemented by CS-23, with the addition of management of pneumonia in the community, will be scaled-up in over 600 districts within the Ethiopian FMOH HEP strategy for CCM, with support from UNICEF. CS-23 promoted this strategy through advocacy at the national and regional levels (Annex 2). F3. Attention to Equity SC's CS-23 project focuses on expanding access of sick and healthy child services to disadvantaged rural areas as part ofthe FMOH HEP strategy. The districts chosen, although not the poorest districts in SNNPR, are considered disadvantaged within Ethiopia. The MTE was not able to assess the socio-economic equity impacts of the project; however, the baseline KPC included measurement of household characteristics and assets. The endline J[PC should include these same measures to enable analysis of changes in the equitable distribution of intervention coverage in the project areas. The project focuses specifically on the health of women and children. However, the CS-23 team is almost all male, as are the vast majority ofMOH counterparts. In the second phase of the CS￾23 proj ect, attention to gender equity should be emphasized in the recruitment of any positions within the CS-23 project. We reviewed utilization of services by gender of the child (section E) in the MTE and observed no gender preference in Shebedino District. However, in Lanfero districts, it appears that families may be utilizing care for boy children much more often than for girl children, especially for neonatal illness. We were not able to explain this finding during the MTE and it merits further assessment to confirm the magnitude of gender preference in careseeking and determine potential causes and programming options to overcome this inequity.29 F4. Role of Community Health Workers Above we have discussed the community-based health workers in great depth; the HEWs who provide services and promotional activities at health posts, in the community and through household visits, and the vCHWs who promote key family practices in the community and households. The CS-23 project, during the MTE, completed the beta version of the 29 Soon after the MTE field work, the CS-23 team did a review of all sick children who visited 2 health posts in Lanfero, for a total of nearly 500 cases from IMNCI registers and did not find this sex difference; the full assessment will be completed soon. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 34 URCIUSAID "CHW assessment and improvement matrix (CHW AIM),,3o in order to better describe the cadres of community workers. Annex 7 includes the CSHGP CHW matrix and the CHW AIM as applied to the CS-23 project. F5. Contribution to Global Learning The implementation ofIMNCI at the health posts, even in the absence of pneumonia management, is one of the first in the SNNPR and serves as a learning experience at the regional and national levels. Lanfero and Shebedino Districts are among the first in the country to introduce zinc treatment for management of diarrhea. In coordination with PSI, SC trained health providers and provided zinc supplies in 2009. The CS-23 project continues to support the introduction of zinc and is collecting data related to zinc treatment at health posts and caretalcers' follow-up visits to HPs. The CS-23 project and MOH partners shouldfurther document their experiences with zinc, drawing on the quantitative data collected at health posts, and share with local and national stakeholders in the beginning stages of zinc introduction. Additionally, the CS-23 project conducted formative research to assess and propose potential improvements to supervision within the REP system; a full operational research proposal for REP supervision strategies is under development. G. Conclusions and Recommendations Overall, the CS-23 project has successfully supported the implementation of the complete package ofIMNCI in facilities and the community. Its activities have and will serve as a model for implementation of comparable initiatives in Ethiopia. The grant to SC from UNICEF to implement IMNCI in the community in 62 districts using a similar approach is a good measure of the CS-23 project's success. The activities and implementation are on track at mid-term; however, utilization of maternal, child and neonatal services remain a challenge. In IMNCI, the CS-23 project can now progress to: 1) strengthen implementation further; 2) improve utilization; 3) intr'oduce pneumonia management in the community in light of the recent policy change; and 4) develop a transition plan to ensure sustainability after the close of the project. The transition plan may include consideration to develop a follow-on child survival project that could leverage, inform, and scale up best practices found in CS-23. The CS-23 project should build on its success in introducing and supporting INMCI, as well as reinforcing capacity and relationships with the MOH at all levels, to introduce and implement stronger strategies to improve neonatal health. In summary, the primary recommendations at mid-term include: 31 IMNCI service availability, quality and health practices o Continue support to DHOs and health workers in the implementation ofIMNCI. 30 University Research Co. and USAID. Assessing and Improving Programs Extending Health Services to Communities: The Community Health Worker Program Assessment and Improvement Matrix (CHW AIM), DRAFT FOR BETA TESTING. April 2010 .. 31 See sections C and E for more details regarding recommendations. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 35 o Conduct initial and refresher training through CS-23 or in coordination with pminers, including: ., Initial IMNCI training for newly assign HEWs and HEP supervisors; • Pneumonia management and treatment training for all the HEW S32 and HEP supervisors; • Refresher training in IMNCI for HEWs, HEP supervisors and health center staff; and ., Initial and refresher c-IMNCI training for new and previous vCHWs and HEWs. o Propose standard guidelines for treatment and tracking of sick children seen by HEWs in household visits. o Strengthen the system for referral and referral feedback through: a) strategies to facilitate referral; b) creating community demand for referral feedback; and c) provision of referral slips (with feedback sections) to all levels. o Strengthen stock management system and coordination with RHB and local health officials to ensure adequate IMNCI drug availability; including rapid assessment of causes of CoArtem® stock-outs. o Ensure availability ofIMNCI supervision checklists (pending review ofRHB and new HMIS) at all levels and provide "on-the-job" training for the use of checklists where necessm'Y￾DReview two-month supervision training package with govemment partners and advocate for inclusion ofIMNCI supervision in package; in interim ensure 5-day training for HEP supervisors. DDevelop a package of low cost incentives-such as certificates and in-kind incentives from child-survival related campaigns-for HEP supervisors, HEWs and vCHWs in coordination with local health authorities and communities. Neonatal Health Component o Provide essential newborn care training using postnatal visitation package from WHO/UNICEF/SC reprogrammed from treatment of sepsis activities due to delay SNL resem'ch. o Promote postnatal home visits and peri-natal promotional activities by team of female volunteers and mothers-to-mothers groups led by HEWs. o Target perinatal behavior change activities to fathers and grandmothers. o Leverage and advocate with other partners for Safe and Clean Delivery training for HEWs. Partnerships, advocacy and transition plan o Continue the strong collaboration with the national FMOH and regional and local levels health authorities. o Continue child survival advocacy activities at international, regional and local levels. o Coordinate and leverage with partners to: a) strengthen drug supply availability and stock systems; b) provide clean and safe deliver training; and c) supply clean delivery kits. 32 This is supported by UNICEF through Save the Children in Lanfero and Shebedino districts; therefore there may be opportunities to re-program funds to other, unfunded needs. CS-23 Ethiopia, MicI-Tenn Evaluation, October 2010 Save the Children 36 o Develop a transition plan for the close of CS-23 project in coordination with partners and stakeholders that addresses: a) drug supply, with emphasis on zinc; and b) continued supervision ofIMNCI activities at BCs, BPs and in the community. Monitoring, evaluation and operational research o Improve CS-23 routine monitoring thl'Ough: a) incorporation of non-smvey based indicators; b) indicators linked to the target population; c) district-dis aggregated estimates; and d) analysis of time trends. o Support the government BMIS in coordination with routine CS-23 monitoring where feasible. o Assess, verify and explore causes of gender preferences in Lanfero District. o Investigate and document reasons for low utilization of child health services in Shebedino in order to develop approaches to increase utilization. o Carry-out operations research to test alternative, promising strategies for motivation and supervision within the BEP strategy pending DBO, RHB, and FMOB concurrence. H. Action Plan Please see Annex 15. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 37 ANNEX 1: RESULTS HIGHLIGHT Best Practice: Implementation of the comprehensive IMNCI strategy in health centersl health posts and communities in Shebedino and Lanfero Districts of SNNPR1 Ethiopia. Save the Children (SC) is implementing a USAID/CSHGP Child Survival Project (CS-23) to reduce under-five mortality among 69,491 children 0-59 months of age in Lanfero and Shebedino districts, SNNPR, Ethiopia. Through CS-23, Save the Children has implemented all three pillars of the Integrated Management of Neonatal and Childhood Illness (IMNCI) to improve curative services for sick children, especially in the community.l The three-pronged IMNCI strategy is considered a best practice, although is very rarely implemented in practice. 2 A baseline health facility assessment found that health posts (HPs) did not have the training or supplies to deliver IMNCI services to children in the community. In collaboration with the Regional Health Bureau (RHB) and NGO partners, Save the Children: • Trained and supports 102 Health Extension Workers (HEWs) in IMNCI at 55 health posts, resulting in coverage of approximately 2 HEWS and 1 HP per 1000 children under five; • Supports the health system to provide supplies, drugs and regular supportive supervision for IMNCI , including the introduction of zinc for diarrhea management; and • Trained, equipped and supports volunteer community health workers (vCHWs) and HEWs to promote essential family practices, including careseeking and home care. HEWs now have the skills, supplies and support to appropriately assess, classify and treat cases presenting with fever and diarrhea; assess and treat children with malnutrition and assess, classify and refer children with pneumonia or danger signs. The results over the first year of full IMNCI implementation in the two districts include:3 • 14,700 children under-five treated with antimalarials for RDT+ or clinical malaria (fever) annually (291 malaria/fever cases treated per estimated 1000 children under-five) ; • 10,346 children under-five treated with antibiotics for pneumonia annually (205 pneumonia cases treated per estimated 1000 children under-five); ., 7,017 children under-five treated with ORS for diarrhea annually (1,927 with ORS and zinc) annually (139 diarrhea cases treated per estimated 1000 children under-five) The implementation of the comprehensive IMNCI strategy, especially among HEWs at HPs, was the first kind in the region and recognized by the RHB and in NationallMNCI review meeting as a model for scale up. UNICEF will support a similar strategy of IMNCI in communities in 600 districts, implemented by the Ethiopian health system and NGO partnersl including sc. The IMNCI strategy now includes pneumonia management/treatment by HEWs in the community. 1 See Gove, S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. Bul WHO, 1997. 2 Bryce J, Victora CG, Ha bicht J PI et al. Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness. Health Policy plan 2005;20 SuppI1:i5-i17. 3 Utilization also takes into account IMNCI services provided at health centers; Health centers also received IMNCI training and supplies and are part and parcel of IMNCI strategy. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 38 Save the Children ANNEX 2: LIST OF PUBLICATIONS AND PRESENTATIONS As an active member of the national child survival working group; SC has played an advocacy role, generated and shared knowledge about local best practices and widely disseminated their experiences to a wide range of audiences during annual review meetings, professional association's annual conference and other relevant workshops at the international, national and regional levels. These include: . (1st of pres~htatlonslp,u~licatlons . ~ • to whom .. 1. CS23 project overview for partners Regional Health Bureau) Sidama & Silti Zone Health Departments, to lanfero & Shebedino DHOs, UNICEF, JSI/ESHE, GOAL, Plan International 2. CS23 project over view Regional CS task force which includes RHB, UNICEF,WHO, JSI and international NGOs in SNNPR 3. Community Case Management Improves Annual conference of the Ethiopian Pediatric Use of Treatment for Childhood Diarrhea, Society, close to 100 pediatricians in attendance. Malaria and Pneumonia in a Remote District (SC also distributed articles on pneumonia CCM) of Ethiopia 4. CS23 project overview CS Technical Advisory group which Includes MoH, UNICEF, GOAL Ethiopia, JSI/IFHP, Malaria Consortium 5. CS23 project overview and achievements Regional, Zonal and District Health offices review presentation meetings 6. Dissemination workshops on KPC and HFA RHB, Sidama and Siliti ZHD, Lanfero & Shebedino baseline findings DHO 7. Experience of operationalizing Zinc GOAL CS MTE workshop treatment in CS23 project 8. Community Case Management Improves International Multilateral Initiative on Malaria Use of Treatment for Childhood Diarrhea, symposium November 2-6,2009 in Nairobi Kenya Malaria and Pneumonia in a Remote District of Ethiopia 9. CS23 project overview and achievements Africa Regional Pan-Africa Every One Campaign presentation Workshop, February 18-20, 2010 Addis Ababa 10. CS23 project overview and achievements National Orientation and launching workshop on presentation CCM: Nazareth, Ethiopia. Donors, implementing partners and RHBs 11. Presentation on CCM esp of Pneumonia Regional level workshops and CS task force 12. Evidence, Advocacy, and Partnerships for Save the Children Program Learning Group Community Case Management of Childhood Norwalk, CT, USA. Infection in Ethiopia: The End of the Beginning lisf ofrepqrtslPiQJ.i.~atiorls .. 0 ... ·.··:c .. : ':. :: ~t;~5 "~Ii !.- , . " .. 1. Formative research on the HEP supervision (unpublished report) 2. Degefie T, Marsh D, Gebremariam A, Peer-review publication in Ethiopian Journal of Tefera W, Osborn G, Waltensperger K. Health and Development from previous project to Community Case Management Improves advocate for inclusion of pneumonia treatment Use of Treatment for Childhood Diarrhea, Malaria and Pneumonia in a Remote District of Ethiopia Ethiop. J. Health Dev. 2009;23(2) 3. Quarter and annual activity and financial RHB, Sidama and Siliti ZHD, Lanfero & Shebedino CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children ~ Date March 2008 March 2008 May 2008 November 2008 June 2009, March 2010 August 2009 September 2009 Nov 2009 Feb 2010 Feb 2010 April 2010 June 2010 . . September 2009 2009 Jan, Apr, Jul 39 reports to government partners DHO and to Regional Bureau of Finance 4. KPC and HFA baseline reports to key RHB, Sidama and Siliti ZHD, Lanfero & Shebedino partners DHO 5. Integrated/Joint supervision reports Sidama and Siliti ZHD, Lanfero & Shebedino DHO 6. Training reports in IMNCI RHB, Sidama and Siliti ZHD, Lanfero & Shebedino DHO 7. Training report in C-IMNCI RHB, Sidama and Siliti ZHD, Lanfero & Shebedino DHO 8. AWD outbreak reports Lanfero RHB, Siliti ZHD & Lanfero DHO CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children & Oct 2008- 10 August 2009 Aug, Oct, Mar 2009 July 2009 Feb & Nov 2009 Dec 2009 40 ANNEX 3: PROJECT MANAGEMENT EVALUATION PLANNING Project documentation and interviews with government partners and other key stakeholders confirm that the project's planning process has been inclusive since inception, engaging at the national, regional, zonal, and district levels. Development ofthe original application and DIP, the MTE team, and MTE workshop held 9 August 2010 were all participatory events. Save the Children participates on the SNNPR Regional Child Survival Task Force and on several technical working groups at the national level. The DIP and work plan are coordinated with district planning and guide implementation in the two districts. Going forward for the last two years ofthe project, the work plan will be adjusted in the area of training and strengthened for tracking and monitoring. SUPERVISION OF PROJECT STAFF Save the Children's EtCO supervisory system for SC staff, as described in the DIP, is adequate, fully institutionalized, and maintained. Challenges of the supervisory system for service delivery, as it applies to the project and its service providers, is described in detail in the MTE report. HUMAN RESOURCES AND STAFF MANAGEMENT In February 2010, the project added two field positions for Community Mobilization Officers to strengthen coordination with local community leadership and follow up of the vCHWs trained in c-IMNCI. The presence of CMOs in the field has paid off in increasing structure and routine meeting schedule and monthly planning for delivery of key messages by vCHWs. Annex 3, figure presents an updated organigram and the CMO job description is presented in Annex 3, Box. Shortly after the MTE, it was announced that Dr. Tedbabe Degefie, Head of Save the Children's Health Unit in the Ethiopia Country Office, would be leaving in October 2010 to take a position at UNICEF in Ethiopia. Dr. Degefie has been with Save the Children since May 2000. The EtCO and CS-23 team looks forward to working with Dr. Degefie in her new role in Child Health/Newborn Health at UNICEF. FINANCIAL MANAGEMENT Save the Children's financial management system, as detailed in the DIP, appears to be adequate and accountable at headquarters, country, and field levels. Save the Children's CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 41 spending is on track; it has not submitted a budget amendment, and no major budgetary adjustments are planned at this time. Adequate resources are in place to finance operations and activities planned for the remaining two years of the project. One challenge cited by the project team is that per diems for IMNCI facitator~/trainers were under-budgeted and are below current market standards. For this reason, Save the Children has found it difficult to recruit facilitators/trainers. The project team is working with the EtCO in Addis Ababa to secure special approvals to adjust per diem payments to at least the level of the Ethiopian Pediatric Society approved standard for IMNCI facilitators/trainers. LOGISTICS Early in the project, a delay in raising private funds for procurement of the project vehicle was a major challenge. This delay lasted nearly a year until Save the Children's Survive to Five Campaign (now called Where the Good Goes) agreed to raise the necessary funds for the vehicle, as well as to cover procurement of zinc and other essential drugs to fill supply gaps. INFORMATION MANAGEMENT Section C in the body ofthe report details the project's research, use of data, and outcomes, including system for collecting, reporting and using data and measuring progress toward project objectives. TECHNICAL AND ADMINISTRATIVE SUPPORT The team reported that technical and administrative support have been adequate to meet project needs. Dr. David Marsh, Save the Children's Senior Child Survival Advisor and Community Case Management Team Leader, continues to backstop the project technically from headquarters. Additional programmatic support (match) is provided by Africa Regional Health Advisor Karen Z. Waltensperger based in South Africa, and by Westport-based staff who assist with finance, documentation, and coordination. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 42 Position Title: Location: Reports to: Grade: Annex 3, Box: Community Mobilization Officer Job Description SC/USA - ETHIOPIA COUNTRY OFFICE: JOB DESCRIPTION Community Mobilization Officer Shebedino (Sidama Zone) and Lanfero (SHiti Zone) Child Survival (CS-23) Health Program Coordinator C1 General description: Incumbent is expected to provide a consistent and high quality technical support in relation to community mobilization activities. The position holder will assist the program officers in each PU to build strong and workable community mobilization intervention packages and there by strengthening the implementation of one ofthe key CS23 strategy Community IMNCI to deliver key health messages at community level. Specific Responsibilities: ~ Organize community groups, generate community resources and educate them on sustainable community involvement in the uptake of C-IMNCI interventions ~ Using the behavior change strategy in CS23 for the C-IMNCI implementation, mobilize the community around the promotion of key newborn, child and maternal health key messages ~ Educate community groups on C-IMNCI promotion and implementation ~ Organize communication activities such as workshops, focus groups seminars, and other training activities for HEWs, volunteers and among local community groups. ~ Support on-going monitoring of capacity building and effectiveness of mobilized community interventions ~ Adapting and developing appropriate training manuals for community voluntaries. ~ Develop and disseminate experience-based learning on community mobilization specific to CS23 program in SNNPR ~ Together with the Health Program Coordinator and District Health Officers conduct an assessment of community structures, local service providers, peer educators and social mobilizes who can assist the incumbent to implement wide ranging community mobilization activities in maternal, newborn and child health . ~ Coordinate with project coordinator to ensure consistent community mobilization in the target districts ~ Prepare and submit routine project activity reports. ~ Document lessons learned and success stories. ~ Demonstrate effective team building and communication skills to maintain harmony and work efficiency in the unit. ~ Work closely in C-IMNCI implementation with Health Extension workers and volunteer community health workers (VCHW) to deliver the key maternal, newborn and child health messages ~ Work on feasible strategies to effectively reach households and Plan and implement C-IMNCI with HEWs and VCHWs ~ Work closely with ME officer and the District HEW supervisors for close monitoring of C-IMNCI implementation Minimum Requirements: • Bachelor Degree in Social Sciences/Public Health/Nursing/Communications or any other related field with 4 years of relevant work experience of Diploma in one of these fields with 5 years of relevant experience. • Knowledge, training and experience in C-IMNCI and community mobilization/BCC • Demonstrated skills in program planning, implementation and monitoring. • Demonstrated skills in peer group training, Training ofTrainers and development of training materials. • Proficiency in spoken and written Amharic and English. • Strong computer and interpersonal skills. • Demonstrated ability to work effectively in a team environment. CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 43 Annex Figure: Organizational Chart and Project Organigram ------------------------------------------------------------ SC/Dept. of ' SC/Africa Regional Director John Mitchell (Ethiopia) SC/DHN Associate Director Carmen Weder Health & Nutrition SC/Saving Newborn Lives T . . ..' .......... , ... . SC EtCO DIrector :-:-:-:-:-:-David'Marsh:':-:-:-:-:-: -:::::::i;(··ttil>At(..:·······:-:-:-: FMOHUNICEF Ned Olney .' ';wJf!6, ---',.Grpiip,·Y1i¢i: . . . . ..Team .......... ..... Dnver .. Offlce .... -:.:-l / ' I :::<_-J -- " \' .. :"" .......... :. ,........... . ................... 1>1_--:-:-:-:-.... ,,:r / \ Z()l"1aIHealth . . . . . . . . . . . . ... . . . >: ..•.• ! , '\ I I " '\' I , \' \ ,>/>:;, ":-/,' : <,,,,-, -,;," : / \ : -f, \·[£anferoTlistribt:·J : I / '" \ ': .. ; .. " ''' ... : .... ,,:;:: .. :\.:::':.; .. '. ' .................... ' 'Health;Mana ement : Shaded boxes indicate partners' 'm' 'm' . : "ht:-:':':-' / -,-1.···.·· :i:",- .;.: ..... : ... g.;.: .-.- .... :. ' j •••• "'" ................... ,- ,-. ..... .. . .. ' patterned boxes are child survival ::::::::Mobiiizatlort:::::::: :::::::CS:p(Qj:e.ct:Qnlce{s:::::::: -/' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i project core implementation team :::::::::::):infce{s::::::::::::: " : clear boxes are SC support. ::::::::::::::::::(2:(:::::::::::::::: : __ ; _________________ ______________ SC EtCO ..... ...... - - .... - . . ..................... . ..................... . .... -.-............................... . ANNEX4: WORK PLAN TABLE OBJECTIVE MAJOR ACTIVITIES .. MET?· ._ . ACThllTYSTATUS .. NQiE:UC:Qmp/~t~d/pn"goingll signifies that theac;tivityhas been successfully carri(!c/outin.tllefirs.t phase. of theprojectand will continue· in ihe:nelsiphase of the project as well. ... .. . .. .•.. . . .. .. Intermediate resylt I: Access and availability of services and supplies increased Activity 1. Train health workers including Health Extension Workers in IMNCI Activity 2. Provide standard IMNCI algorithms to assess, classify and treat symptoms of diarrhea, malaria and pneumonia for health centers and health posts Activity 3. Train community health promoters in C-IMNCI Activity 4. Facilitate prompt referral of sick children from community to health post & severe cases from HP to health center Activity 5. Strengthen prompt & effective assessment and appropriate treatment of diarrhea and malaria by trained HEWs Activity 6. Strengthen prompt & effective assessment and referral of pneumonia by trained HEWs Activity 7. provide/facilitate for health centers and health posts with essentiallMNCI drugs to treat diarrhea and malaria Activity 8. Provide/facilitate availability offirst line antibiotic to treat pneumonia at health centers Activity 9. Ensure adequate supply of antimalarial and new formula ORS at health center and health post level Activity 10. Ensure adequate zinc supply/stock at health post (HP) & health center (He) Activity 11. Start zinc treatment for diarrhea at HC and HP Activity 12. Advocate at regional & national level through established child survival groups and UN organization to start CCM/pneumonia by trained HEWs Activity 13. Ensure adequate supply/stock of first line antibiotic for pneumonia at health posts Activity 14. Start community case management of pneumonia at health posts by trained HEWs Activity 15. Follow up for adequate supply and distribution of ITN at HC & HP Activity 16. Follow up for adequate supply and stock of childhood vaccines at HC & HP CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children YES Completed Completed Completed Partial Completed/ On-going Completed/ on-going Completed/ on-going Completed/ on-going Completed/ on-going Completed/ on-going Completed/ on-going Completed Not completed Not completed Completed/ on-going Completed/ on-going 109 HEWs & 13 HC workers trained in IMNCI in 2009 All HCs and HPs equipped in 2009 with IMNCI job aids; available in 2010 MTE (see results section) 1080 vCHWs trained in 2009 No New FMOH permits the treatment of pneumonia with antibiotics by HEWs; in remaining years of project, HEWs will treat pneumonia IMNCI drugs procured & distributed; Stock shortages and financial resource constraints threaten on￾going support Policy change in 2010 to include CCM/P by HEWs, implementation scheduled to start in Sept/Oct 2010 MOH policy/practice did not support AB treatment by HEWs until late 2010; to be started in 2010 with support from UNICEF and completed in 2011, 2012 Support for ITN distribution in transportation; LL ITNs primarily supplied through campaigns Supportive supervision; larger stock issues remain a challenge 45 · , " ,OBJECTIVE, " MAJORACIIVITIES, 'ACnVITYSTATUS', " ". MET? : < '; ';" " , " NOrE:~:~0'f'p,etedfoK~tJoingt~ig~ifiestha.ttheactivitYhasbef!~suci:essf~!ly.c(1rried:outirith,efirstp.h(1seoltheii{cijf!cfdn~wiil 'c~ntiAuJintHe"ne;ftl;fia;~"of,the pro]eb{'ds weW' '/; '< ;7: :'<;'.' •••. ' "C' ...• >" ".'.' ,',tc;.·'}[;' ', .• ~ ''S';'' . Activity 17. Promote routine and outreach immunization Activity lS.Avail a trained HEW and a health professional in essential new born care and assessment of sick new born Activity 19. Avail a trained HEW & health professional in safe delivery, newborn care, assessment, resuscitation & postnatal care Activity 20. Strengthen the link between TBAs & HEWs in follow up of deliveries, newborns to provide essential newborn care & postnatal care Activity 21. Strengthen the referral link of sick newborns to health centers for early & prompt management Activity 22. Follow up for availability of safe delivery kit and newborn resuscitation equipment at health post & health centers Activity 23. Support n immunization and availability at health post Activity 24. Avail standard Job aids (IMNCI reference materials, wall charts, teaching aids, IEC materials) in child health Activity 25. Avail standard registers and reporting formats Activity 26. Monitor and follow up for essential drugs & supply & facilitate corrective actions Intermediate Result 2: Quality of services increased Activity 1. Train health professionals in IMNCI case management skill (how to assess, classify, treat & counsel) pneumonia, malaria & diarrhea, newborn & sick young infant Activity 2. Train HEWs in IMNCI case management and referral skill (assess, classify, treat, counsel)of pneumonia, diarrhea, malaria, newborn/sick young infant Activity 3. Facilitate/provide with IMNCI essential drugs & supplies for health centers and health posts. Activity 4: Follow up for appropriate drug treatment at HP & HC level Activity 5: Fo"ow up for proper counseling and follow up at health post & HC Activity 6. Facilitate rehydration therapy with the new ORS formula Activity 7: Facilitate zinc treatment for diarrhea CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Completed/ on-going Partial No/partial Partial Partial Partial Completed/ on-going Completed Completed Completed/ on-going Completed Partial Completed/ on-going Completed/ on-going Completed/ on-going Completed/ on-going Completed/ on-going Done by HEWs and vCHWs with support from MOH partners & CS￾23 Essential newborn care include in IMNCI training; Sick NN Activity on hold pending results from SNL research Only 10 HEWs trained in clean and safe delivery (5 in each district) Reporting formats provided; HEWs liaising with TBAs well for follow￾up, although links not standardized or institutionalized Few sick newborns seeking care at either HPs or HCs Supplied by UNICEF; Partial availability of safe delivery kits - no resuscitation equipment supplied Through supportive supervision A" standard IMNCI job aids & registers distributed & available day ofMTE visit Through supervision and coordination; on-going challenge to ensure drug stocks at all levels 13 HC workers trained in IMNCI in 2009 109 HEWs HC workers trained in IMNCI in 2009; HEWs not trained in pneumonia or sick newborn mgmt due to policy issues Drug shortages are on-going challenge (purchased with supplementary finds) Provided with IECJob aids ORT corners set-up & ORS formula available In coordination with PSI 46 OBJECTIVE ~ , ' - - - - - , , ' , ,', ',. . MAl OR. ACTlyiTI ES MET? ", :ACTIVrrYSTATUS - • N()TE:7tgJjJpletedl(J,!~gQing"signijies tha.t the actillity has peen 5uccessjullycarriecjout if! the/iist eh,ase pfthe p"aject andWiII cantinue in the. next phase af the prajectas, we/l . .. " Activity 8. Give regular on the job trainings and technical assistance in IMNCI implementation at health post & health centers Activity 9:Train HEWs in assessment of sick newborn, in essential newborn care messages (IT immunization, cord care, thermal management & recognition of newborn danger signs) Activity 10: Support/build capacity of health workers and District Health Office staff in proper supervision and routine monitoring, in sustaining facility & community level activities Activity 11: Review quality improvement options with partners in delivery of MCH services and design OR protocol Activity 12: Review regional data collection/HMIS in standard documentation and reporting to make them user friendly Activity 13: Conduct baseline rapid health facility assessment survey Activity 14: Strengthen existing supportive supervision for HEWs jointly with district health office health center staff Activity 15: Facilitate use/adoption of standard supervision checklists inclusive of curative services and counseling services Activity 16: Avail Standard job aids for reference and documentation (registers, reference job aids for key messages delivery, IMNCI reference materials/algorithm) Activity 17: Conduct joint review meetings and feed backs on performance on regular basis (recognize best performances) Activity 18: Ensure use of standard reporting formats and registers Activity 19: Strengthen the link between HEWs &TBAs/nBAs in essential newborn care and post natal care Activity 20: Support & facilitate child immunization Activity 21: Promote on early treatment of sick child for fever, diarrhea & pneumonia Activity 22: Planning, design monitoring & evaluation and KPC training for child survival M&E officer Activity ;!3: Facilitate annual technical updates with professional associations on child survival Activity 24: Annual progress review & planning meeting Activity 25: Performance progress monitoring survey Activity 26: Participatory midterm evaluation led by external consultant Activity 27: Review midterm assessment and MTE findings & recommendations with MOH and partners, prioritize & CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Completed/ During joint supervisions and visits on-going by SC staff This was provided to HEWs as part Completed of the IMNCI training Completed/ Regular joint supervision and on-going review meeting occurring On-going Review of challenges and options, protocol under development Completed / Review mtg held in 2009, new on-going HMIS requires on-going efforts Completed Completed/ Joint supervision for 1M NCI on-going conducted throughout project Partial Supervision checklists specific to IMNCI under review by RHB Supplies distributed and available Completed at HCs and HPs Completed/ Conducted regularly throughout on-going project Completed/ on-going Partial Links established, but not standard Completed/ Promotion of immun, facilitation of on-going stocks, and member of EPI TF Completed/ vCHWs on-going Completed Membership, participation and Completed/ presentations at national, regional on-going and district child survival task forces Completed/ Close relationship with RHB & local on-going health authorities Planned It is included in year 3 plan Completed Completed MTE was participatory, with results and recommendations workshop; 47 '1- .• J -,. " , ,,-, .' ~.-" .' OBJ.ECTIVE " ,,' . , ., , " ,. .. MA.ldi(ACTIVI;ri ES .. ' ... ··MET? "ACTIVITY:STAJU51' ;;i' ,": -, '~ ,,:' ".,'. .- 'i ' . .- . 7'., ,'. NCY{Ef/'CQmpletedlol1;gqing;' signijiestlidft/Je'activity' hiis.·been successfu(ly Ciirried, out. in' the:flrstphas.e'of the', prol'e'cfcma,will i:~ritih'J~fri'th~~~lctj;H(j~~oftl1ep"r;;jf!'(;Y'i:f~W~I/;,)~,~~:;SYi~:< "\' .......'/;>; ......,; .', " ":'<,/,.". schedule actions to address recommendations, & plan for required actions Activity 28: Conduct end line rapid health facility assessment Activity 29: Conduct endline KPC survey Activity 30: Final evaluation led by external consultant Intermediate Result 3: Knowledge and acceptance of key services and behaviours increased Activity 1: Train HEWs and VCHWs in delivery of key messages in child health, nutrition, care seeking behaviors/practices, child/maternal/newborn danger signs, essential newborn care, postnatal care, hygiene & sanitation Activity 2: Adopt/develop education materials/teaching aids for key messages in child health, in appropriate behaviors & practices Activity 3: Conduct community leaders sensitization workshop Activity 4: Provide health promotion activities in health facilities in child health, nutrition, care seeking, hygiene and sanitation during one to one sessions or during health education Activity 5: Deliver key behaviors & practices in appropriate care seeking for ill child, in recognition of signs needing proper treatment, in recognition of danger signs through trained HEWs and VCHWs at household level Activity 6 : Promote on appropriate hand washing practices Activity 7: Promote standard immunization services during health facility visits Activity 8: Promote on proper oral rehydration at health facilities and home during diarrhea Activity 9: Counsel/advise caretakers on proper feeding and fluid during diarrhea episodes Activity 10: Counsel caretakers in proper breast feeding, proper feeding for infant & young child and feeding during illness Activity 11: Counsel caretakers in one to one and in groups about household sanitation & hygiene (proper hand washing, safe waste disposal & safe water storage/treatment) using trained HEWs & VCHWs Activity 12: Inform community on ITN availability and proper utilization by children & pregnant women Activity 13: Ensure caretakers understanding of importance of referral and follow up of sick child Intermediate Result 4: Social and policy environment enabled. and sustainability of all activities improved Activity 1: Develop project agreement with Regional Health Bureau (RHB) and key stakeholders CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Not yet completed - planned for endline YES Completed Completed Counseling cards, leaflets and boo klets distributed Completed On-going Health Education sessions; Using IEC materials On-going On-going On-going On-going On-going On-going On-going On-going On-going YES Completed 48 '-';2-'--' ..... OBJECTIVE·· . ,.-- , . , . ': -'-.' . MAJORACTIVITIES MET? ..... ·ACTIVl.TY,StATU~ .,. . ' .. .' . . 'NOT¥:',:comple:terJlon~gqinrl' fifmififsthat the activity has been siiccessfqll}/cgJri/!f;lout in. thefirs! phase o/the jJ~oiect and will . continue in the next phase o/the project as well ' ' ., Activity 2: Collaborate with RHB and other partners on child survival working groups at regional and national level Activity 3: Work with GoE/NGO/UN partners for policy improvement in HSDP-IV, esp CCM of pneumonia by HEWs Activity 4: Document and disseminate evidence based best practices in CCM using MoH guidelines and documents Activity 5: Conduct joint planning with relevant & key partners and community stakeholders in CCM (develop detailed implementation plan) Activity 6: Lead regular partners coordination, advocacy and policy dialogue in CCM and evidence based new born & child practice Activity 7: Adopt proven child health interventions and strategies in to regional and national policies and programs Activity 8: Conduct joint and integrated supportive supervisions and TAs Activity 9: Follow up of health facilities functionality in IMNCI implementation and reporting Activity 10:Facilitate proper health service delivery by health posts in collaboration with MoH and partners Activity 11: Support and facilitate standard documentation and regular reporting by health posts & health centers Activity 12: Standardize the referral link between HEWs and TBAs/VCHWs in safe & clean delivery & postnatal visit Activity 13: Participate and advocate through Save the Children Health & Nutrition (PR3) Program Learning Group Activity 14: Conduct first regional dissemination workshop (Awassa) Activity 15: Final dissemination workshop Activity 16: Participate in periodic regional child survival taskforce meetings Activity 17: Document and share child survival interventions & updates in regional review meetings Activity 18: Support and participate in national child survival taskforce to advocate for policy change in CCM Activity 19: Establish regional TAG (Technical Advisory Group with representation from RH B, Regional Child Survival Coordinator, Hawassa University, UNICEF, WHO, ESHE, Malaria Consortium) Activity 20: Conduct regional TAG meeting Activity 21: Establish district level child survival team (MoH, SCI others working on CS) Activity 22:Document of the CCM/P experience to inform CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children On-going Completed On-going 17 CCM best-practices d issem i nated Completed (on-going for routine planning) On-going Completed/ on-going Completed/ on-going Completed/ on-going Completed/ on-going On-going Documentation and reporting at HPs needs further strengthening Not yet HEWs (except X) not trained in SCD, some links between TBAs/CHW & completed HEWs, but not standardized Completed (see presentations list) Completed Not yet completed, planned at endline Completed/ on-going 2-4 times per months Completed/ Reports shared regularly with RHB, on-going ZHD and DHO Completed/ on-going Completed Completed/ on-going Completed Established in 2009 Completed Documentation/presentations of 49 • < OBJECTIVE< • < NO IE: "cotrip";~ted/bnfgoJili:( slgniJies; tHat tHe activity has< ~;~':.;, .. i;1":;~'::6S +h~;:'~::u,' ',';; ,.:;' .... ; .. :..,; .;i..': .' "'.}: ".: "".:, ... ;: .:.c;;;.~;, ">'(';",;, .. : : ::// .• ;,.s·c.·;·· '., '~5 : Vitamin A Supplementation in the Last 6 Months Description -- Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother's recall Numerator: Enter the number of children age 6-23 months who received a dose of Vitamin A in the last 6 months (mother's recall or card verified) Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino, District 120 244 49.2% 10.8 Lanfero District 131 200 65.5% 13.0 .. . " . ,: .•.. ' •.• ,. .. ',,';»",;'. ,; .:,:. ,,. :.,; .. ? ',.' ';" . ',,"" . :. ':"., •• :•• "', ,'" './:': ".' ";;:':"'~.':::; ;,/,;,:,' '. ,.: i'c,:,.;'.::;; • • /.,;,';.! ,.:.:.,. "., •• ,;;': :.: ,';';, " ',.'.,' Measles Vaccination Description -- Percentage of children age 12-23 months who received a measles vaccination Numerator: Enter the number of children age 12-23 months who received a measles CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 79 vaccination by the time of the interview as seen on the card or recalled by the mother Denominator: Enter the total number of children age 12~23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino DistriCt 72. 126 57.1% 15.8 Lanfe(o ,District 80 122 .65.6% 16.7 Access to Immunization Services Description ~~ Percentage of children age 12~23 months who received DTPl according to the vaccination card or mother's recall by the time of the survey Numerator: Enter the number of children age 12~23 months who received a DTPl at the time of the survey according to the vaccination card/child health booklet or mother's recall Denominator: Enter the total number of children age 12~23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence . Limits Shebedino,DistriCt . 96 li6 76.2% 17.0 80 122 65.6% 16.7 Health System Performance Regarding Immunization Services Description ~~ Percentage of children age 12~23 months who received DTP3 according to the vaccination card or mother's recall by the time of the survey Numerator: Enter the number of children age 12~23 months who received DTP3 at the time of the survey according to the vaccination card/child health booklet or mother's recall Denominator: Enter the total number of children age 12~23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District 62 126 15.0 Lanfero District 50 122 41.0% 14.3 Treatment of Fever in Malarious Zones Description ~~ Percentage of children age 0~23 months with a febrile episode during the last two weeks who were treated with an effective anti~malarial drug within 24 hours after the fever began Numerator: Enter the number of children age 0~23 months with a feb~ile episode in the last two weeks AND whose mother/caretaker sought treatment for the child within 24 hours AND who were treated with an appropriate anti~malarial drug Denominator: Enter the total number of children age 0~23 months with a febrile episode in the last two weeks Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits . Shebedino District 9 300 19.1% 16.8 Lanfero District 32 49 65.3% . 26.3 CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 80 ORT Use Description -- Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids Numerator: Enter the number of children age 0-23 months with diarrhea in the last two weeks AND who received oral rehydration solution (ORS) and/or recommended home fluids Denominator: Enter the total number of children age 0-23 months who had diarrhea in the last two weeks Sub Area Name Numerator Denominator Percent (calCulate) Confidence Limits Shebedino District 61 97 62.9% 18.5 Lanfero District 26 62 41.9% 20.3 . k:;;;!i~:!;;:;Ei'~;~~j~V~~!l~~cfS!ii" !;.;i,·:{:~~.; •. ii~.:;:: ·i.i~;' J,; ;.';z;; i •. ' :c;;,s ••. · ;;~;.;;I~;j.tS·.;;:~:?:P:J:;i·.;'{r ;;;:;\." .' ••• Appropriate Care Seeking for Pneumonia Description -- Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Numerator: Enter the number of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Denominator: Enter the total number of children with chest-related cough and fast and lor difficult breathing in the last two weeks SubArea Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District 27 84 32.1% 15~7 Lanfero District 16 51 31.4% 20.0 ~;'£·~;;~;5;;Y.=Z;;~~;,.~ij'~fi';~;; .....;.:; .... ;;;··n;·;;r;:;[;'; ... ;';;;:.?~~'/.;.~{ ............ .ii; ;;;.L<~i:.;Cs;}.::;;;~;;;SJ:~;i}.;.';~:; ... . Point of Use (POU) Description -- Percentage of households of children age 0-23 months that treat water effectively Numerator: Enter the number of households of mothers of children 0-23 months that treat water effectively Denominator: Enter the total number of households of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District .49 300 16.3% 6.2 L.anfero District 16 300 5.3% 3.6 Appropriate Hand Washing Practices Description -- Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing CS-23 Ethiopia, Mid-Telm Evaluation, October 2010 Save the Children 81 Numerator: Enter the number of mothers with children age 0-23 months who live in households with soap at the place for hand washing Denominator: Enter the total number of mothers of children age 0-23 months in the survey, Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Sheb.edino. District 100 300 33.3% 8.4 Lanfero District 50 ·300 16.7% 6.3 Child Sleeps Under an Insecticide-Treated Bednet Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bed net (in malaria risk areas, where bed net use is effective) the previous night Numerator: Enter the number of children age 0-23 months who slept under an insecticide￾treated bed net the previous night Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Shebedino District 109 36.3% Lanfer" District 144 ~~~~~~~ Underweight Description -- Percentage of children 0-23 months who are underweight (-2 SO for the median weight for age, according to the WHO/NCHS reference population) Numerator: Enter the number of children 0-23 months with weight/age -2 SO for the median weight for age, according to the WHO/NCHS reference Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Shebedino District 46 277 Lanfero District 65 271 CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children Limits 16.6% 6.5 24.0% 7.7 82 Rapid Catch Indicators: Mid-term Sample Type: Maternal IT Vaccination Description -- Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child Numerator: Enter the number of mothers with children age 0-23 months who received at least two tetanus toxoid vaccinations before the birth of their youngest child Denominator: Enter the total number of mothers of chiidren age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence limits Shebedino District % Lanfero District % t.,~{.~·}0;ft>i$"};I\·; '~;,"~.';,];~,< ~('·;r/.t:0 .c:.'... ••.• . ... . ·~;:·~~~: •• ;l··· ~......:~.. '.y .......... ;. ........ .,T ....•... "::.,,"J<:, '.; •.. •. ' ". '; • Skilled Birth Attendant Description -- Percentage of children age 0-23 months whose births were attended by skilled personnel Numerator: Enter the number of children age 0-23 months whose birth was attended by a doctor, nurse, midwife, auxiliary midwife, or other personnel with midwifery skills Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence limits Shebedino District % Lanfero District % ' • .;. .. >' ".: : ·t. ;;;'X;F;.~/'.· <:2';(. . ••• :5 ••• ·~: . .,. . . ... ..... . ' ... " .. ,;:; .. :; ... ,'.; .,.',1..:.·,,'·;'.'; .... '.. .' ... ... Post-Natal Visit to Check on Newborn Within the First 3 Days After Birth Description -- Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within three days after birth Numerator: Enter the number of children age 0-23 months who received a post-natal visit within three days after birth by an appropriate health worker Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence limits Shebedino District % Lanfero District % ." .' .', :: '.' .. , Exclusive Breastfeeding Description -- Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours Numerator: Enter the number of children age 0-5 months who drank breast milk in the previous 24 hours AND did not drink any other liquids in the previous 24 hours AND was not given any other foods or liquids in the previous 24 hours Denominator: Enter the total number of children age 0-5 months in the survey CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 83 sub Area Name Numerator Denominator Percent (calCulate) Confidence Limits. Shebediho District % Lanfero District % Infant and Young Child Feeding Description -- Percentage of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Numerator: Enter the number infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator· Denominator Percent (calculate) Confidence . Limits. Shebedino District % Vitamin A Supplementation in the Last 6 Months Description -- Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother's recall Numerator: Enter the number of children age 6-23 months who received a dose of Vitamin A in the last 6 months (mother's recall or card verified) Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator . Percent (calculate) Confidence Limits . Shebedino District % Lanfero District % Measles Vaccination Description -- Percentage of children age 12-23 months who received a measles vaccination Numerator: Enter the number of children age 12-23 months who received a measles vaccination by the time of the interview as seen on the card or recalled by the mother Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District Access to Immunization Services Description -- Percentage of children age 12-23 months who received DTP1 according to the vaccination card or mother's recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received a DTP1 at the time of the survey according to the vaccination card/child health booklet or mother's recall CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 84 Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District % .' .'. :. > ..' '.t:;'~"'. . :l' ..r. 'J:,' ,.:..';,:: ; "':" .. : .. ", '. ... ', .' Health System Performance Regarding Immunization Services Description -- Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother's recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received DTP3 at the time of the survey according to the vaccination card/child health booklet or the mother's recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) . Confidence Limits Shebedino District % Lanfero District % li;;:\::;;;':::;;~:" .". ' ..... , .. -.. ::- .. ' " . ::, ":""c.,y;,,,;: ;t.-·':f; "-"':'? '."" .... : :;;ff':%;~'F;:';:: ',:-':"';',: -. .' . - -:. '-," '-. ,; .... .: '. Treatment of Fever in Malarious Zones Description -- Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial within 24 hours after the fever began Numerator: Enter the number of children age 0-23 months with a febrile episode in the last two weeks AND whose mother/caretaker sought treatment for the child within 24 hours AND who were treated with an appropriate anti-malarial drug Denominator: Enter the total number of children age 0-23 months with a febrile episode in the last two weeks Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District % " '.' < .• '. ::-'.;:.': ::::';:·f"'.;:.,> ; ':::':>:': «-'.' ,:: ;':"~/ ·';<:N".'; ::¥:.'.;;;; <:,. to:: '. ; .. J:' ,. -f:.;:;:." :";"v'.-';;;;;;;'. ORT Use Description -- Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids Numerator: Enter the number of children age 0-23 months with diarrhea in the last two weeks AND who received oral rehydration solution (DRS) and/or recommended home fluids Denominator: Enter the total number of children age 0-23 months who had diarrhea in the last two weeks Sub Area Name Numerator . Denominator Shebedino District Lanfero District CS-23 Ethiopia, Mid-Te1ID Evaluation, October 2010 Save the Children Percent (calculate) Confidence Limits % % 85 Appropriate Care Seeking for Pneumonia Description -- Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Numerator: Enter the number of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who \(IIere taken to an appropriate health provider Denominator: Enter the total number of children with chest-related cough and fast and lor difficult breathing in the last two weeks Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Point of Use (POU) Description -- Percentage of households of children age 0-23 months that treat water effectively Numerator: Enter the number of households of mothers of children 0-23 months that treat water effectively Denominator: Enter the total number of households of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District % Appropriate Hand Washing Practices Description -- Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing Numerator: Enter the number of mothers with children age 0-23 months who live in households with soap at the place for hand washing Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator· Denominator Percent (calculate) Confidence Limits . Shebedino District % Lalifero DistriCt . % Child Sleeps Under an Insecticide-Treated Bednet Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bednet (in malaria risk areas, where bednet use is effective) the previous night Numerator: Enter the number of children age 0-23 months who slept under an insecticide￾CS-23 Ethiopia, Mid-TelID Evaluation, October 2010 Save the Children 86 treated bednet the previous night Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) ; Confidence Limits Shebedino District % Lanfero District % .. ;< . .... v;;:. :' '?i'; .';' .' ',;"'" i;".'., . ':,e!'; i.>:' ',';"i; 'i; : : .. : '.. >;." "; i';" """.i;.'" ',,;., f >. >,. , Underweight Description -- Percentage of children 0-23 months who are underweight (-2 SD for the median weight for age, according to the WHO/NCHS reference population) Numerator: Enter the number of children 0-23 months with weight/age -2 SD for the median weight for age, according to the WHO/NCHS reference population Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator ' Denominator Shebedino District Lanfero District CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Percent (calculate) Confidence . Limits % % 87 Rapid Catch Indicators: Final Evaluation Sample Type: Maternal TT Vaccination Description -- Percentage of mothers with children age 0-23 months who received at least two Tetanus toxoid vaccinations before the birth of their youngest child Numerator: Enter the number of mothers with children age 0-23 months who received at least two tetanus toxoid vaccinations before the birth of their youngest child Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate)ConfiCience . Limits Shebedino District % Lanfero District % Skilled Birth Attendant Description -- Percentage of children age 0-23 months whose births were attended by skilled personnel Numerator: Enter the number of children age 0-23 months whose birth was attended by a doctor, nurse, midwife, auxiliary midwife, or other personnel with midwifery skills Denominator: Enter the total number of children age 0-23 months in the survey . Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % % Post-Natal Visit to Check on Newborn Within the First 3 Days After Birth Description -- Percentage of children age 0-23 months who received a post-natal visit from an appropriately trained health worker within three days after birth Numerator: Enter the number of children age 0-23 months who received a post-natal visit within three days after birth by an appropriate health worker Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Exclusive Breastfeeding Description -- Percentage of children age 0-5 months who were exclusively breastfed during the last 24 hours Numerator: Enter the number of children age 0-5 months who drank breast milk in the previous 24 hours AND did not drink any other liquids in the previous 24 hours AND was not given any other foods or liquids in the previous 24 hours Denominator: Enter the total number of children age 0-5 months in the survey CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 88 Sub Area Name Numerator Denominator Percent (calculate) .' Confidence Limits Shebedino District % Lanfero District % . ·C·. '.y,':> ' c/ .•..•. /. ; .... .... •... :" ...... . :L : ,: .' : .' .> ' .. ' ,Infant and Young Child Feeding Description -- Percentage of infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Numerator: Enter the number infants and young children age 6-23 months fed according to a minimum of appropriate feeding practices Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District % . ',',; :~..: : :.:......: .;:. . .... : .::. . " . . ...... ...:::;::::':';': . ..::' ;;:'::~<"':'<::>"'·";/'>'.'i':': .' ".' ,:",::~:,,;, :; : .. ;;J;...:, .' .; '. .': .' '., Vitamin A Supplementation in the Last 6 Months Description -- Percentage of children age 6-23 months who received a dose of Vitamin A in the last 6 months: card verified or mother's recall Numerator: Enter the number of children age 6-23 months who received a dose of Vitamin A in the last 6 months (mother's recall or card verified) Denominator: Enter the total number of children age 6-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District % : .;;,::,"~;~.,;' ··;c .• c· .': ",' ";:': ,,;:' ;."~'~'~"':.':;;:" >:.> . :,'..».:: " ... :'';;'''':' ".: ;...., .',""'iJ:} ,", i"::' .c ••.... ,,' •.... · .. ·:i : ...• : .'. Measles Vaccination Description -- Percentage of children age 12-23 months who received a measles vaccination Numerator: Enter the number of children age 12-23 months who received a measles vaccination by the time of the interview as seen on the card or recalled by the mother Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District % . / .:': •. "·:"f:'.;~:·: '·'i:: 1 "',::.1 ."" ...... , , .. ~: .:' '/ ,~.\:.:.,,::; .. ,,::.; ..... .. .. ' ... .""", .".',':.' . ':':"::"::" :c.·':·,·. Access to Immunization Services Description -- Percentage of children age 12-23 months who received DTP1 according to the vaccination card or mother's recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received a DTP1 at the time of the survey according to the vaccination card/child health booklet or mother's recall CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 89 Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino, District % Lanfero District % .• i~:?ii:"';~; ':;;;:2< .. ; .. '.:';·d.· ... :~;·G2~G~i.i;~M'"i.c;.c,,:; .' .;... ii;"!"" ". .~;, .. , .... ,., <.e;G ',;";.2,;;,,;;," Health System Performance Regarding Immunization Services Description -- Percentage of children age 12-23 months who received DTP3 according to the vaccination card or mother's recall by the time of the survey Numerator: Enter the number of children age 12-23 months who received DTP3 at the time of the survey according to the vaccination card/child health booklet or the mother's recall Denominator: Enter the total number of children age 12-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedirio District % .. Lanfero District % •• ·.(;.:;·.;~~;.f~;[~~~~J~~~~f~:ili.f~;.i1~~;,~J: '. i~~~ ... '.!;.......;~J;,/:.:~;\.;;:;;;~..<';;":· .• ::;:'§T .:;:;.~:.,;Y: ··,·.:::,.;r··.··.',··.· ~.: ... ' ,;2;;;:J;t~·;~~~1~~3;,; .. :. Treatment of Fever in Malarious Zones Description -- Percentage of children age 0-23 months with a febrile episode during the last two weeks who were treated with an effective anti-malarial within 24 hours after the fever began Numerator: Enter the number of children age 0-23 months with a febrile episode in the last two weeks AND whose mother/caretaker sought treatment for the child within 24 hours AND who were treated with an appropriate anti-malarial drug Denominator: Enter the total number of children age 0-23 months with a febrile episode in the last two weeks Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District % '.', ".: ::;:;:f:,·;,'·:~:;;;·:,:, .. ;.;:;;:.;;LJ;,;~/::;" >;: , . ;:~;; ;;.·::~t";.;~};~;~.J,,·/ .. ;~;; ;;;.:i;.;.; •.. :..·;z.}~.:~l;~' ;.;:~; X.;;;;;:;,"; .;. . ORT Use Description -- Percentage of children age 0-23 months with diarrhea in the last two weeks who received oral rehydration solution (ORS) and/or recommended home fluids Numerator: Enter the number of children age 0-23 months with diarrhea in the last two weeks AND who received oral rehydration solution (ORS) and/or recommended home fluids Denominator: Enter the total number of children age 0-23 months who had diarrhea in the last two weeks Sub Area Name Numerator Denominator Percent (calculate) Confidence Shebedino District lanfero District CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Limits % % 90 ; >",,< '<: ;,'~";> , ;' ': " ',:> " /" ", ',,' , '; Appropriate Care Seeking for Pneumonia Description -- Percentage of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Numerator: Enter the number of children age 0-23 months with chest-related cough and fast and/or difficult breathing in the last two weeks who were taken to an appropriate health provider Denominator: Enter the total number of children with chest-related cough and fast and lor difficult breathing in the last two weeks Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero DistriCt % '?;~"q~t}f;~r:~i{~::t:;~.,)'t':~;( ;';;;;)~; '.. ,'.', X '."', '5 '<' .'" . ;.>, ,,'?i';'i,;; .' ,,'eX .... ,. • '::J;;,;~'i}";~);~"G;~\ >,,;~, . Point of Use (POU) Description -- Percentage of households of children age 0-23 months that treat water effectively Numerator: Enter the number of households of mothers of children 0-23 months that treat water effectively Denominator: Enter the total number of households of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero District % "; '{ ,; >" , '~:~i;,;:; :;,~:;) ::~:;;~~';1; 77>'; ;;':X\,' 'z" . " ':",~;;X'5:};f:)~X' i;'::;/,,: :;;):',:;;'z,:;,y;'; .. ," ,;:~':l:'R:i'/':;;;·:' ,': ~, Appropriate Hand Washing Practices Description -- Percentage of mothers of children age 0-23 months who live in households with soap at the place for hand washing Numerator: Enter the number of mothers with children age 0-23 months who live in households with soap at the place for hand washing Denominator: Enter the total number of mothers of children age 0-23 months in the survey Sub Area Name Numerator Denominator Percent (calculate) Confidence Limits Shebedino District % Lanfero DistriCt % 'c' ".' , '", " , 'j ,/"",'; / ;,:; : 'i,'" :;,;::;;::' ',i..".' '. .... " .' ". '0, '.:: • , ; ',' c, Child Sleeps Under an Insecticide-Treated Bednet Description -- Percentage of children age 0-23 months who slept under an insecticide-treated bed net (in malaria risk areas, where bed net use is effective) the previous night Numerator: Enter the number of children age 0-23 months who slept under an insecticide￾CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 91 treated bed net the previous night Denominator: Enter the total number of children age 0-23 months in the survey Sub Area Name Numerator Denominator . Percent (calculate) Confidence Limits Shebedino District % Lanfero District % c,,- .···.:Pi::.·,;:;'.· : .• '?' '~?:ii:G"~~;;;:~~~':';'~?;~';;I'r)"~:'r<~";;51%~;;t':~;l'?t'iM.;;;.! •.• j~~~~,e;~;~l::k, Supply 4000 water guard 4. Supply 3500 Flayerlleaflet about AWD '*-- Supply 440 liter of petrol to the district health office for motor bikes Table 2.5 Activities and financial expense by Save the Children for AWD No Activities Quantity Budgeted Expense in Birr in Birr I Supply water guard 4000 16000 16000 2 Supply Flayer/Leaflet on AWD 3500 7000 1400 3 Rent a Vehicle 22 days 17850 17380 4 Supply petrol for District H.Office 440 liters 6160 6160 5 Fuel for the rented vehicle 4000 2000 Total 51010 42940 ($3997) ($3365) Report on A WD outbreak response, Lan/era District - Dec 2009 7 Balance (%) 0 (100%) 5600 (20%) 470 (97.4%) 0 (100%) 2000 (50%) 8070birrJ$632 (84.2%) 5 SC CS-23 Ethiopia MTE, Annex 12 8 ANNEX 12 - Section 2 9th Annual Regional Health Partners Forum & EFY 2002 Mid-year Review Meeting Report, 8-10 March, 2010. SC CS-23 Ethiopia MTE, Annex 12 9th Annual Regional Health Partners Forum & EFY 2002 Mid-year Review Meeting Report 8-10 March, 20 I 0 Hawassa, SNNPR Reported By: Elias Kayessa Health Program Coordinator Worlm Tefera Monitoring & Evaluation Coordinator 8-10 March, 20 10 Hawassa SC CS-23 Ethiopia MTE, Annex 12 Part I: 9th Annual Regional Health Partners Forum (March 8, 20 10) Place of Meeting: Hawassa Venue: Sidama Cultural Hall Date: 8 March, 20 10 Organized by: Regional Health Bureau Participants: RHB SMT member, WHO, UNICEF, International and Local NGOs, Zonal Health Department Heads, Woreda Health Office Heads, Hospital Managers Hospital Medical directors and Health Extension Workers representatives Purpose of partners Forum discussion: • To build common understanding and consensus on key health and related problems and their interventions • To coordinate and harmonize of individual partners activity in order to avoid duplication of effort and efficient utilization of limited resources • To introduce and discuss on CCM of pneumonia policy change Proceedings of Annual Regional Health partners Forum Partners' forum meeting was started with welcome opening remark of RHB head and followed by key note address of UNICEF, WHO, Ireland Aid representatives focusing on their program areas and appreciating the policy change on CCM of Pneumonia treatment by health extension workers at health post level especially by UNICEF. Presentations on partners' forum progress to date, donors mapping, Implanon and IMNCI initiative progress challenge and the way forward, research and technology transfer issues and 2003 EFY Woreda based National planning and HSDP-IV strategic themes were presented by different RHB representatives and discussion made point by point. Finally on CCM of pneumonia the participants discussed point by point and appreciated the change made to save the life of children with treatable disease where there is well trained HEWs. Good points ./ Partners mapping document prepared in collaboration with BoFED ./ 165 CSOs Regional HIV?AIDS partners resource mapping was conducted ./ HMIS Technical Working Group reformed ./ Emergency response to epidemics was good ./ Harmonization and coordination of partners at Woreda and community level improved ./ Integrated supportive supervision done by partners together with RHB 9th Annual Regional Health Partners Forum & EFY mid-yr review, SNNPR - Mar 2010 2 10 SC CS-23 Ethiopia MTE, Annex 12 Wealmesses raised during discussion were: if only one RJSC meeting if Uncoordinated trainings at Woreda level and overburdened the staff if Weak participation of few partners on planned activities e.g. MSH if Irregular training payment creating discrepancy at lower level if Zonal level poor ownership on coordination Point given more emphasis • In Woreda based planning partners should participate in their respective project area • Use One plan, One budget and One report principle at each level • Training guides, time schedule and payment needs uniformity • Integrated supportive supervision has to be appreciated at each level Partners Forum assignment (elected) I. Dr. Haile Mariam Legesse (from UNICEF- Coacher) 2. Dr. Gebre (from WHO - Secretary) Part II: RHB EFY 2002 Mid-Year Activity Progress Review Meeting Conference (March 9-10,2010) Highlights of the conference Participants of the conference RHB SMT member, WHO, UNICEF, International and Local NGOs, Zonal Health Department Heads, Woreda Health Office Heads, Hospital Managers Hospital Medical directors and Health Extension Workers representatives Objectives of the conference • To reviewing EFY 2002 mid year plan versus achievement • To discuss on HSDP-IV themes and woreda based EFY 2003 health sector annual plan development • To brain storm on CCM policy change and how to proceed with • To discuss on the need of re-planning on poorly performed activities of EFY 2002 activities for the remaining months of the fiscal year • To discuss on previous quarters supervision findings and next improvement actions • To discuss on the need of strengthening one plan, one budget, one report Important points raised on the conference (selected for the purpose of this report) After opening speech by RHB head, the EFY 2002 mid year report was presented by the concerned process owner of the Regional Health Bureau using PowerPoint segregating by Zones and special woredas plan versus achievement. 9th Annual Regional Health Partners Forum & EFY mid-yr review, SNNPR - Mar 2010 3 11 SC CS-23 Ethiopia MTE, Annex 12 After presentation of the report participants asked questions that need clarification and also raised their concerns on the content of the report and challenges they faced during activity implementation. The participants raised vaccine and kerosene as a major problem; however, the RHB head replied that the RHB do not have the problem of vaccine and kerosene shortage except lack of timely settlement of accounts to get the next round money on regular basis. He underlined, "woredas have the mandate and allocated budget to purchase kerosene; no room to expect budget from Zone or Region." Also it has identified that there are Zones and special woredas that are not requesting supplies and logistics before the stock is nil that has great impact on performance. The participants agreed up on to re-plan the poorly performed activities. Later on, supervision feedback report has presented and discussions were made on the strengths, weaknesses and on the areas that need to be improved. As of the findings of the supervisory team, capacity building trainings are given by different organizations or government on the same and similar topics at the same place and for the same people that need to be improved by implementing one plan, one budget, one report to organize the implementation of trainings and other activities too. The RHB head has suggested that before the implementation of all trainings the Zonal health desk and woreda health offices have to recognize and approve the training for effective and efficient use of the scarce resource and to avoid training duplications. ITN supply and use: the conference participants and key officials from the RHB have acknowledged the existing ITN has supplied before three years and obsolete to be used by households. The consensus on ITN issue is, there is a plan and preparation by the RHB to re-distribute in this EFY (2002) for rural households. Problem of water supply: there is high shortage of water in Welayeta Zone including the capital of the Zone, Sodo, as of the presented report. Availability of training registration books: As reported on the conference, there are training registration books at health facility level to monitor and control the categories and composition of trainees to prevent giving repetitive chance for a single individual, however, reported that there are no registration books in some health facilities. This is very good experience to be adapted by our office to control the status of training in all our projects under ASO. Partners extra support: In some woredas there are some NGOs that are rendering support like maintaining motorbikes out of their agreed activities. Such activities are appreciated and recognized by the RHB officials by announcing the names of NGOs in some woredas supported the government. Health Education Impact Assessment (Welayeta Zone experience): Welayeta Zone presented its experience on how they are monitoring behavioral change among the community. Depending on their pre set schedule, every week they go out to visiting 9th Annual Regional Health Partners Forum & EFY mid-yr review, SNNPR - Mar 2010 4 12 SC CS-23 Ethiopia MTE, Annex 12 HPs and also visit 10 PAs under the health post to inquire mothers to assess their knowledge and skills on key indicators using checklists. Institutional delivery: Overall in the region, institutional delivery is less than 5% while delivery by Health Extension Workers is 32% (from 6 months plan) compared to 6.8% in EFY 1994. However, it has emphasized that a lot of work is in front to mobilize the community to use health facilities for delivery service. Brain storming on CCM policy change: Basically the participants were not against CCM policy, but have doubt whether it can be managed by HEWs or not, also there were some participants who were arguing that this is additional burden on health extension workers to fulfill the 16 packages as of the HEP policy. Finally the RHB head summarize and commented that there will be launching meetings and trainings at all levels to clear how to proceed with CCM. One plan, one budget, one report issue: As a summary the following points were given attention and discussed: need of all partners to plan with the government, submitting their budget to the government on paper for common understanding, submitting quarter and annual reports to the government (RHB, BoFED and DHO), need of participating on government Integrated Supportive supervision (ISS). Complaint raised from the RHB is, some NGOs have started to participate on ISS, but some are disappearing before the completion of the supervision activity which is quoted as unfair. 9th Annual Regional Health Partners Forum & EFY mid-yr review, SNNPR - Mar 2010 5 13 SC CS-23 Ethiopia MTE, Annex 12 14 ANNEX 12 - Section 3 SNNPR, Regional Health Bureau. Mid-term evaluation for: Enhancing Ethiopia's Health Service Extension Program in the Southern Nations and Nationalities People's Region (SNNPR), Save the Children Child Survival Project. June 2010. ~ ____ ~~~~~~~~1~~=-==~~~~~~~~~~~'~'~~'~'~====9 I SC CS-23 Ethiopia MTE, Annex 12 I 'M'1'D '1"'!£'Rl !£'VU 'Up. '1"''1 o'lf PO'R I ! I I .'1 I !Enfiandna !Ethfoyfa's a-lfaCth Service !Extension Program in tfie . Southern I}(at£ons ana 1{at£onaUt£es Peoyfe'5 'Reaion (st]{tJ{p1?v), cfii~d Survivaf Pnject I , Save: the ChiCdren ruS!Il I June 2010 Enhancing Ethiopiu's Health Service Extension Progran) in the Southern Nations and Nationalities People's Region, Save the Chlldrell I USA '-f~ 15 \ " \ , SNNPR BlrED Mid Term gYalualionRLrogmm the Soulhcrn Nations and Nationalities People's R~gion, Save the Children lJSA G 19 Ibiiz: -::: :-..,.-"'"'---, '--". t... o N N '<""" s:::: s:::: « ill I- ::2: co '0. o :c W C'? CiJ U) () () U) SNNPR BoFED Mid Tenn Evaluation Report Chapter Two . Physical and Financial Accomplishment Provide pneumonia casemanagernent when recional Health Bureau Diarrhea.and malaria management skill ,building at Health Post and .Community level IMNCI training for .healthpmfessional in the Health Center j Skilled delivery service, ,newbpm care& Health Post and.Health Centers Ensure ,an integrated at health post and health centers for child health nutrition and sanitation Avail pr:oper newborn care, assessment, .postnatal visit strategies by HEWs! CHPs/CRPs at health post level EnhllDcinj?; Ethiopia's HeaIth·Serv.ic.f\ Prt\Ot"Q .... u, th- >.'1"":_-'''''''-- n" '.' centers level -"""'" ..- C\I C\I X . tv w .j:>. SC CS-23 Ethiopia MTE, Annex 12 Annex 1: Child Survival Project (CS23) MTE Debriefing Workshop Schedule MID-TERM EVALUATION: REVIEW OF OBSERVATIONS FROM THE FIELD AND DEVELOPMENT OF PRELIMINARY RECOMMENDATIONS CHILD SURVIVAL PROJECT (CS-23) Enhancing Ethiopia's Health Extension Package in the Southern Nations and Nationalities People's Region (SNNPR) in the Districts of Shebedino (Sidama Zone) and Lanfero (Siltie Zone) August 9, 2010 Time Activity Responsible 8:30-8:45 Participant Registration Barassa 8:45-9:00 Opening Remarks RHB head 9:00-9:15 Child Survival Proj"ect Overview CS Program Manager 9:15-9:30 MTE Methods CS M&E Coordinator 9:30-10:00 MTE Key Preliminary Findings Consultant 10:00-11:00 Small Groups - Interpretation and Participants in 4-5 small preliminary recommendations with tea groups 11:00-12:00 Small Group Presentations Small group reporters (each group 10 minutes) 12:00-12:30 Wrap Up and Next Steps CS Program Manager & Colleague 12:30-1:30 Lunch MTE Participatory workshop for preliminary results & recommendations - NFR 4 35 SIn 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 SC CS-23 Ethiopia MTE, Annex 12 36 Annex 2: Child Survival Project MTE Debriefing Workshop Participants August 9,2010 Name Organization Position Abdulkerim I MEan Days reported Stock-Out • Average I!ISbebedino o L:al1fero· 80 97 · Pentavalent-3 vaccination in Shebedino and Lanfero districts, Ethiopia7 Pentavalent-3 Vaccination 2008 2009 2010 Shebedino Per 1000 expected births* lanfero Per 1000 expected births* Annex 13, Figure 1: Selected AcUvit~es from last Supervrnsion Visillt to Health PDst by Dllistrkt {%) Ob$erv.,~d!C(iru il'if Sle){"l'5 o to n = 6- HP in Lanfero:;md 4 HP'in Shebedino 40 eo Percent -Average ElShebecflM bll""f'~r(l 1Q'0 TOTAL Per 1000 expected births* 7 Original indicator was DPT3, as selected before the introduction of pentavalent vaccination. CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 98 Save the Children Annex 13, Figure 8~ Selected Activities from last Supervrusiofl Visit to Health Center by District (%) r····---·-·~-,· ~--~··1 ~~.--.-- J;A'Il!mge· 4!} Bil 100 Percent Annex 13. Figure 9: Case Management of Non-Severe Pneumonia Scena rio at Health Post by District (%) .Average aShebedino [] Lanfero Refer Correct Classification UseTimerwithSecondHand ' C hec k Co ug h 0 uration Check CI 1==lIm=.II.m CheckRR _. ~----,,-----,------.------,~ Che ck General OS ilIShe-1Jedlc\-1l ol.m~lero o 20 40 Percent 60 80 100 n= 7 HP In lanfero and 4 HP in Shebedino CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 99 Annex is. Figure 10: Assessmel1t~ Classificatioll & Treatmellt of Non..;Severe Pneumonia Scenario at Health .Post by District (%) Treat Cfassify o 20 n:: 7 HPj n LsnfE rD ,and 4 H f>i n ShEbal'in{} CS-23 Ethiopia, Mid-Tenn Evaluation, October 2010 Save the Children 40 6'0 Percent -AveralJe IllShebedino o Lanfero 80 100 100 Annex 13, Figure 11~ Case Management of Non-Severe Pneu~nonila Scenario at Healtb Center by District {%} a Avera;ge E1Shebrdino tlLanfero, Uselifmerwith S.ecmndHand Che'Ck Cough Durafion Che,ckC] Check G.eneraLOS o ao 100 Annex 1St Figure 12: Assessment, Classification & Treatment of Non-Severe Pneumonia Scenario at Health Cent,er by District (%) Treat CTassify As'sess {) 20 n = 4 HCin L3nfer'Danrl3 HCln:5hebedino CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 40 60 P,ercent .Av~mge EI Shebetilno o Lanf~rlo 80 100 101 Annex 13, Figure 13: Consistent) (omplete 0.3 episodes per child per year; Malaria: Approximately 1 episode per child yr, as estimated for relatively low transmission area (Roca-Feltrer, Carneiro, Schellenberg TMIH, 2008) (NOTE - May be higher in Lanfero district); Diarrhea: Approx 5 episodes per child per yr in Africa, Boschi Pinto, Lanata & Black in International maternal and child health. Ehiri JE, Meremikwu M (Eds), Springer Pub., Washington, DC. In press. **Includes cases treated for pneumonia and fever/malaria CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 105 Annex 13, Table 7: Utilization, treatment and treatment ratios over time in Lanfero district, Ethiopia Lanfero district (Data from SC & HM/S routine reports) , I lOne EC year (Q3 Treatment Est. US 2008 2009 2010 2009 to Q2 2010) per est. cases per I Total # of 1000 US year in • 4th Q Q1 Q2 Q3 Q4 Q1 Q2 children per year district" ¥ All sick child visits at Hesi 1,885 2,865 5,508 5,375 7,7r )6 11,080 7,322 119 102 Treat￾ment ratio ------ _._-------- All s!ckchildvisits at HPs I 298 I 3,215 I 1,210 1,219 3 6 L""/. ! , I 'lJ ! /. u;52 3,322 1,822 1 Children treated with antibiotics I 534 I 1,042 I 1,716 I I .,.,// I LOU.' 0.;-]' L .. ULI (for pneumonia) at HCs** Children referred for pneumonia [to HC] at HPs Children treated for Fever/malaria at HC (clinical or RDT+) Children treated for Fever/malaria at HP (clinical or RDT+) TOTAL Fever/Malaria Children treated at HC with ORS for diarrhea Children treated with ORS at HPs for diarrhea TOTAL Diarrhea (with ORS) Children treated at HC with ORS and Zinc for diarrhea Children treated with ORS and Zinc at HPs for diarrhea TOTAL Diarrhea (withzinc & ORS) 700 21 I 1,064 I 1,385 I 2,941 141 3,082 849 0 849 283 370 0 370 261 2,618 1,439 4,057 853 473 1326 316 220 536 174 58 2,436 1,842 510 480 2,946 2,322 1535 1254 302 231 1837 1485 0 315 0 153 0 I 468 *Based on population projections of under-five children: Shebedino: 31,356 Lanfero: 19,176 Total: 50,532; 514 27 9,837 513 2,570 134 12,407 647 4491 234.2 1006 52.5 5497 286:7 1001 52.2 373 19.5 1374 71.7 5,753 155% 5,753 9% 19,176 51% 19,176 13% 9,176 65% 5,880 4.7% 5,880 1.0% 5,880 5.7% 5,880 1.0% 5,880 0.4% 95)380·· ·1 1.4% ¥ Based on estimates of incidence: Pneumonia: Pneumonia, the forgotten killer of children (conservative estimate - estimated at >0.3 episodes per child per year; Malaria: Approximately 1 episode per child yr, as estimated for relatively low transmission area (Roca-Feltrer, Carneiro, Schellenberg TMIH, 2008) (NOTE - May be higher in Lanfero district); Diarrhea: Approx 5 episodes per child per yr in Africa, Boschi Pinto, Lanata & Black in International matemal and child health. Ehiri JE, Meremikwu M (Eds), Springer Pub., Washington, DC. In press. **Includes cases treated for pneumonia and fever/malaria CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 106 Annex 13. Table 8: Utilization, treatment and treatment ratios over time in Shebedino and Lanfero districts Total: Shebedino & Lanfero district(Data from SC & HMIS routine reports) One EC year (Q3 Treatment 2008 2009 2010 2009 to Q2 2010) per est. Total # of 1000 U5 children o 654 I 1564 I 1954 I 2490 I 3750 I 2152 10346 204.7 o o 0 I 35 I 391 I 217 I 102 745 14.7 776 1,15712,08713,25213,25512,851 12,344 11702 231.6 o o 0 I 212 I 1474 I 592 I 720 2998 59.3 106.5 32.3 138.9 425 27.1 o *Based on population projections of under-five children: Shebedino: 31, 356 Lanfero: 19,176 Total: 50,532; Est. # of U5 cases 15,160 15,160 50,532 50,532 252,660 252,660 252,660 252,660 Treat￾68.2% 4.9% 23.2% 5.9% 2.1% 0.6% 2.8% 0.5% ¥ Based on estimates of incidence: Pneumonia: Pneumonia, the forgotten killer of children (conservative estimate - estimated at >0.3 episodes per child per year; Malaria: Approximately 1 episode per child yr, as estimated for relatively low transmission area (Roca-Feltrer, Cameiro, Schellenberg TMIH, 2008) (NOTE - May be higher in Lanfero district); Diarrhea: Approx 5 episodes per child per yr in Africa, Boschi Pinto, Lanata & Black in International maternal and child health. Ehiri JE, Meremikwu M (Eds), Springer Pub., Washington, DC. In press. -Includes cases treated for pneumonia and fever/malaria CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 107 ANNEX 14: "BETA" VERSION OF CCM BENCHMARK INDICATORS (Country) APPLIED TO CS-23 IN ETHIOPIA Country CCM indicators list - Applied to Ethiopia, and CS-23 in 2 districts Overall in Ethiopia HEP CS-23 (Lanfero & Shebedino Specific) Not possible/or unlikely to collect in rapid assessment Supportive I 1I1 ........ ltJ .... • .......... I"oIIII ...... Coordinatio CCM policy nand Policy MOH Setting pOint/unit within I leadership MOH in place MOH-ledCCM stakeholders CCM I. coordination 109 group established and CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Needs checked by Govn't and stakeholders To be completed by Govn't and stakeholders Did not collect in MTE, but could be collected in similar exercises 1_ ""' ....... 1·'.1'1 ... 1' ....... IVI YES. I YES. I YES. I .. I National level National level National level . project; few no: ·other 'NGOs/partr'lers .. , doh1g CCM . now-butwill￾hecomemore. 108 Component 3: Human Resources Cost '. 'estimates for CCM MOH financial contributions to CCM Percentage of active CHWs Retention Rate .com.Ronents estabhshed(Le. supply chain mgt, . training,. etc.) , ' . . . MOH budget includes line item(s) for CCM #ofCHWs providing CCM activities #ofCHWs actively providing CCM CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Targeted # of CHWs #ofCHWs trained in CCM opinion needed on how/ifCCM budgetv. expenditure can be tracked Blue indicator Progress towards CHW target Split between denominators Needs a time dimension builtin; Perhaps more useful in pilot/early phases Govn'tpays HEW salaries,HEPsupervisor salaries, many supplies and support through UNICEF support for new· pneumonia package 104/121 (86%): some HEWs not deployed (or on leave) during training period and 5 HEWs tra nsfe rre d or 104/109 = 95% retention rate in period from early Mar￾2009 to 2010. 38/50 (only 40 HEWs currently deployed) 38/43 trained HEWs 66/71 (only 69 deployed) : 66/66 trained HEWs National level easily obtained in small area or if included in routine monitoring Need to specify a standard time period forthe retention rate (1 year) 109 CHW density I Community Coverage CHW recruitment and job criteria CHW recruitment and job criteria developed and available # of CHWs trained I inCCM # oftargeted catchment areas with access to a CHW trained in CCM CS-23 Ethiopia, Mid-Term Evaluation., October 2010 Save the Cbildren Total population in target communities per 1000 # of targeted catchment areas Unit of measurement catchment area? HH per x population? Requires a mapping of all target catchment areas Important in ea rly stages of program (advocacy and planning stage) 104/333,320 =0.31 HEWs per est. pop of 1000; 104/51,997 =2.0 HEWs . per est. 1000 pop. Of U5s 38/126,487 =0.3 HEW per 1000 est. pop.; 38/19,732 = 1.93 HEWs per 1000 est. U5s 25/25 = 100% 66/206,83 3 = 0.32 HEWs per 1000 population 66/32,265 =2.05 HEWs per est. 1000 U5s 32/35 = 91% (3 urban kebeles previously not targeted; will now be targeted in new HEP) YES. HEWs a recognized cadre within Ethiopian and included in Health Sector Development Plan Depends on denominator - which may vary by source of data (Le. censuses/districts / etc - Le. DOH estimates different than census projections) - used census projections for these estimates All kebeles mapped and supposed to be with HEW in Ethiopia -this will likely be harder to calculate in other countries Without such a structure 110 CHW training plan CHW functionality Retention and motivation plan Sensitization activities Training plan for comprehensive CHW training and refresher training developed # of CHWs actively providing services CHW retention strategies, incentive/motivati on plan developed Percentage of ta rget districts, facilities, and communities sensitized to role ofCHWs # oftarget districts, facilities, and communities sensitized as planned CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Total# CHWs # of target districts, facilities, and communities 1c 1d; Yes/No; Plan must be possible (per resources available) 2a Plan for initial training, unknown for refresher training in broader HEP program for other Plan for initial IMNCI training, but not refresher . training in CS-23 100% (104/104) based on reports received, : etc.; could vary based on other responsibilities in the community FMOH has plan to upgrade to diploma level, but not implemente d yet. Also plan Safe Delivery (trained 5 so 100% kebeles sensitized 100% kebeles sensitized (25/25) 100% kebeles sensitized (35/35) Need to specify denominator more clearly - is this out of trained CHWs, out of target etc? III 'Component, '4:Sup'pIY Chain Manageme, nt Retention and motivation plan review Continuing education plan Registration ofCCM medicines and diagnostics CHW retention strategies, incentive/motivati on plan implemented Ongoing training provided to update CHW on " new skills" reinforce initial training CCM medicines and diagnostics are registered for use at community level Percentage of stock-outs at implementation sites #ofCHWs receiving incentive/motivati on as planned '#ofCHWs participating in , refreshertraining' , ,'" in the last yea r #ofCCM implementation , sites with stock- , Qutsofany c'CM drugs or RDTs ", within the last 30 days'(90 CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children #of functional CHWs #CJfCHWs targe,ted for refresher, training #ofCCM implementati on sites 2c 3b; Needs-a target " " dimension;: "Needs a time . dimension; , Different from check-in: ., :'meetings, etc. Blue indicator; Keep here but needs further discussion - important; Needs to be harmonized NA- paid cadre Safe Delivery training , planned; 'NGOs, etc, on- ,:,1 Refreshertrai.ning part of , gOing '" recommendations of MTE, 'training:in ' ,'various 'aspects; , . formal on- , , going: education plans need ,checked pneumonia management training to be provided in " 4th quarter 2010 Drug Adminand Control Authority (DACA) . approved.ll)dian 'zinc (not certified by UNICEF);DACA approvedORS, '. " cotrimoxazole,CoArtem, etc. P'urchase, not possible without DACAapproval. Stock outof any of4 drugs (CoArtem, Chloroquine, Zinc, ORSj in last 90 days Stock outof one of four drugs in last 90d = 7/7 Stock out of one of four drugs in last90d =3/4 Even if paid cadre, should there be an examination of alternative or supplemental motivation If there is no set, plan,for refresher training (or no refresher training planned, this denominator is difficult to , obtain) ,'Appliedfo(, last: '90 days-,sonot totaJly, . consistent with ',this definition;, Note in some cases CQ initial 'stocks werejust 112 Appropriate' storage for .CCM Percentage dfCCM implementation sites.with drugs.· ahd.RDTs stored in 'implementation sites CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children . ori.sites definition of stock-outs; Or further define delivered so estimate of .stocks7outs may I--=O:-::R:::sc.:s'=O'-:i-n be biased . stock-outs as last 90d= zinc, antimalarials, CoArtem SO ... two more in last 90 d = Chloroquine SO in last 90 d= 1/11 NOT I/Collected .- BUT, could· ,.be ··collectedin. 'similar exercise· NOT' Collected"' :'BUT, ;could ' be. collected in . :similar exercise last 90d = CoArtemsO in 90d = 7/7 CQsO in 90 d=1/7 CoArtem SO in 90d CQsO in 90 d= 0/4 113 !!p; CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children 114 Projected treatment ratio per 1000 children (IT SHOULD NOT BE PER 1000) # 4 on Save the Children (copy) given CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children expected (per 1000 children) in a given catchment area (IT SHOULD NOT BE PER 1000) measure for many countries See (catchment attached areas); tables for Should be He, HPs done annually and overall (dueto for 3 seasonal diseases morbidity); Numerator should be in HMIS 115 Case-load Follow-up visits Number of patient I # of patient encounters at a given site in a given month '# 'visits,compared,to number. protocol' # of sick children referred as compared to # of children assessed during home visits and at the facilities encounters at a given site CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Month Is program improving coverage in community?; Are CHWs over or under-utilized in community; Not sure if this is a good core indicator 3a; ,Not' necessarily follow"ups to facilitY;, There shop,ld,be a , I 'standardized set of Average of 11 sick child encounters per month forEC 2002 Could " potentially be , e,,!racted ,USing detailed' register review; ,on the 11 referred cases out • of 110 extracted = 10% Average of 20 sick child encounters per HP per month for EC 2002 9 referred cases our of70 , extracted = ' 13% Average of5sick child ,encounter s per HP per month 'for EC 2002 referred cases ,out of40 extracted =5% Should be average # of encounters at CCM site per month; no estimate of completeness of reporting - so this may be an over or underestimate : From register extraction; A number of cases referred because of stock-outs of CoArtem 116 Community Coverage Consistent Case areas with access to a CHW trained in CCM/ # of ta rget catchment areas Proportion of CHWswho Management I showed consistency between registered classification of diagnosis and treatment in the last 10 cases of each CHW Correct Respiratory , Rate n Percentage of CHWswho # of catchment with access to a CHW trained in CCM # of CHWs whose registers show consistence between classification and treatment CHWswho CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children # of target catchment areas #ofCHWs supervised #ofCHWs, I #13 #15; Is it +/- 2 ·assessmen t See above 102 consistent cases out of 110 extracted =93% or3breath,s. ,,' NOT ,perrninote?;" . "CGLLEGTE," Evaluation' BUT, ' " criter'ia; Leave could ,be in as space holde'r;,Jet, ' Kate follow, up collected in similar' exercise" 66 37 consistent consistent cases out cases out: of70 of 40 extracted extracted =93 % =93% t',: 117 Communicati Plan for on strategy communication forCCM developed and messages and materials for health staff and community tested and available Knowledge of , " proportionpfcare childhood ' givers who know 2 illness " ,9rmore signs of childhood illness' Fkstsource Proportion of ofc'are caregivers of . children, US in (eM target areas,who' 'as Drs.:t squ(ce"of 'caridorthe sick, . child Component Supervisory Supervisory 7: plans and checklists, Supervision tools guidelines, training and materials, plans Performanc and SOPs available CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Global Potential YES - HEWs and vCHWs trained inC￾IMNCI for key messages Series of yin yes on all- see assessment - although HEP supervision checklist under review pending new HMIS 118 eQA Routine Number ot CHWs supervision who received at coverage least 1 supervisory visit in the prior 3 months during which registers and/or reports were reviewed/ number of CHWs at community level (last supervision Clinical Number of CHWs supervision who received at coverage least 1 supervisory visit in the community during the prior 3 months where a sick child visit was observed and skills coaching provided/ number ofCHWs Supervisor to Number CHW ratio supervisors / number of CHWs CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Children Ilmetrame determined locally 8110 HEWs 516 HEWs report report observation observation of sick child of sick child . care (80%) care (83%) 5110 HEWs 316 HEWs . report report observation observation of sick child of sick child care (50%) . care (50%) 5 HEP supervisors (5 day training)138; 1 supervisorl 38 HEW had 2m training Supervision indicators in our assessment were 314 HEWs collected onlyfor report last supervision observati visit- and on of sick supervision is so child care frequent and (75%) done by many parties (DHO, HEP supervisor, and SC, that this is likely an underestimate) .... .in contexts such 214 HEWs as Ethiopia where report CHWs/HEWs are observati on of sick supervised very child care often, it may be (50%) difficult to get a good estimate of these two indicators 4HEP superviso Trained rs trained supervisor for 5 days turnover (415 166 trained left in HEWs Lanfero and 418 trained left in 119 Correct Proportion CHWs treatment (or proportion of knowledge cases) who correctly prescribe treatment for children with case scenarios Correct Proportion of sick treatmer.lt: children wQo are , practice correctly prescribed . treatment ,fo r' corresponding .. ' illness Component Inclusion of Concise list of CCM 8: CCM in HMIS indicators Monitoring available and & incorporated into Evaluation HMIS framework and Health Standardizati Standardized CCM Informatio on of registers and n Systems reporting reporting documents available for CHWs and HF District Number of monitoring of implementing CCM districts providing CCM monitoring datal number of implementation districts CS-23 Ethiopia, Mid-Term Evaluation, October 2010 Save the Chlldren re., examinatio n 6/6 HEWs = 100% 4/4 HEWs = 100% KI report that iCCM indicators may not be totally incorporated into new HMIS￾but a list exists yes, mostly, especially in SC areas 2 districts/2districtsfor SC monitoring (less clean and clear CCM monitoring for govn't district level) 120 ANNEX 15: ACTION PLAN (September 2010) for Save the Chlldren's Chlld Survival Project: "Innovation for Scale: Enhancing Ethiopia's Health Extension Package in the Southern Nations and Nationalities People's Region (SNNPR), Shebedino and Lanfero Districts "* Assess training needs and cost fo:r health p:rofessionals, health extension wo:tk.e:rs and community health wo:tk.e:rs Map cu:t:tent :resou:tces within SC and among partne:rs in Shebedino & Lanfe:ro Districts newly assign HEWs and HEP supe:rviso:rs in IMNCI HEWs and HEW supe:rviso:rs in new female vCHWS in c-IMNCI trainingl fo:r new and p:revious vCHWs and HEWs standard guidelines fo:r treatment and of sick child:ten seen by HEWs in visits; CS-23 Ethiopia, Midterm Evaluation, October 2010 Save the Children X X X X X X X X X X Iuse MTE conduct stakeholde:rs meeting I CS District Health Office:rs(DHOs) Contact and discuss with I CS P:rogram Coo:rdinato:r partne:rs in Lanfe:ro & Shebedino (plan International, ,Li0K) Integrate it with Ics team UNICEF jICCM Integrate it with ICS team UNICEF jICCM IInteg:rate it with Ics team UNICEF jICCM training I Select female voluntee:rs, I CS team and HEWs I in care Use C-IMNCI guide & CS23 CS team and HEWs budget Use ofIMNCI :reco:rding fo:tms CS M&E Coo:rdinato:r as a :refe:rence, document on a note book, d:tug kit 121 Strengthen the system for referral and referral X feedback services Conduct rapid assessment of causes of CoArtem stock out Strengthen stock management system and coordination with RHB and local health officials A vail adequate stock of essential drugs for BPs in coordination with RHB & DHO Ensure availitbility of ItvINCI supervision checklists at all levels and provide "on-the￾job" trrunillg for the use of checklists where necessary Review two-month supervision training package with government partners and advocate for inclusion of ItvINCI supervision package; Develop a package of low cost and in-kind incentives from child-survival related campaigns-for HEP supervisors, HEWs and vCHWs Ethiopia, Midterm Evaluation, October 2010 Save the Children X X X X X X X X X X X X X X X X X I Facilitate referral; crearing I CS M&E Coordinator community demand for referral feedback; provision of referral slips (with feedback sections) to all levels I Status assessment at Region, I CS Coordinator, DHOs Zone & District level X A vail standard stock cards, IDHOs and M&E check in supervision Coordinator X Monitor stock, Facilitate ICS team, DHOs provision and logistics Use ICCM checklists ofMoH, IM&E Coordinator trrunaspartofItvINCltrrunillg Discuss and collect feedback ICS M& E Coordinator, with partners, being done under ICCM X Certificates for volunteers, ICS EtCO, EveryOne recognition of active campatgn vCHW s,refresher trrunillgs 122 essential newborn. care training using X X X :resource and conduct ostnatal visitation package from tralnlng O/UNICEF/SC X X ISelect female voluntee:rs, /cs team, CMOs leve:rage :resource, use standard guidelines in Matern.al and newborn. care mothe:r to mothe:rs g:roups to p:romote X X X ISl=e GOAL experience, pilot Ics CMOs e:rinatal and post natal p:romotions in some Kebeles by community office:rs and CH facilitato:rs X X X X Retarget during key :MNCH DHOs and CMOs messages delivery X X X X Coordinate and leve:rage with partners to X X X X lTb:tough CS TWG, Leve:rage I CS Coo:rdinato:r strengthen d:tug supply availability and stock systems Coo:rdinate and leve:rage with partne:rs to X X X X lTb:tough CS TWG, Leve:rage I CS Coo:rdinato:r, p:rovide clean and safe delive:r training to :resources DHOs,Partne:rs HEWs Coo:rdinate and leve:rage with partne:rs to X X X X I Contact UNICEF and othe:r I CS Coo:rdinato:r,EtCO clean delivery kits X I CS team and DHO Save the Children 123 Support the gove1::1Jment HMIS ill coordlilation with routine CS-23 monitoring where feasible Assess, verify and explore causes of gender ill Lanfero District Investigate and document reasons for low utilization of child health services ill Shebedlilo Catty-out operations research to test alternative, promisillg sttategies for motivation and supervision withlil the HEP sttategy Follow-up on Zn pilot data - document and dis semlilate x x x x x x x x x x x Inco.tporation of non-survey illdicators;illdicators linked to the tru:get population;district - disaggtegated estimates; and analysis of time ttends M&E Coordlilator Conduct register review for 6 IDPOs months Conduct. assessment of service I CS team and MoH partner utilization CS Manager, Health Unit Senior CS Advisor analysis, share results and [DHOs and M&E up Coordlilator *Workshop conducted at Awassa Haroni Hotel (0900 - 1400 on 9 August 201 0) with the following participants: Hashim Amanzona (Siltie zone Health Department [SiZHD]), Abdulkerim Kamil (SiZHD),Yekesi Mossa(Siitie Zone Finance and Economic Development Department[SiZFED], Bilale Kamil (SiZFED,NGO Affairs Officer), Awol Baid (Lanfero District, Health Office Head),Shemisu Sirmulo(Lanfaro District,Finance), Chiksa Sultan (Lanfero District Health office[DHO]),Tsegaye Yutamo(Sidama Zone FEDD,Abraham Rikiba (Sidama Zone Health Department[SZHD]), Shitaye Hordofa Yonas Hecliera (SZHD)Agaro Godana (SZHD) Yonas Hechera (Shebedino DHO), Bedilu Badego (Shebedino DHO), Azeb Lelisa(Goal Ethiopia), Shiferaw Yelima(Goal Ethiopia),Bekele Demisse (JSI/IFHP/Ethiopis), Esey Batisso (Malaria Consortium/Ethiopia), Hailu Tesfaye (SC/Ethiopia), Worku Tefera (SC/Ethiopia), Elias Kayessa (SC/Ethiopia), Barassa Ware (SC/Ethiopia),Habitamu Tilahun(SC/Ethiopia), Abdulmuhin Nuri(SC/Ethiopia), Yachiso Yaamo (SC/Ethiopia) David Marsh (SC/HQ), Karen Waltensperger (SC/Africa Region), and Kate Gilroy (JHU). CS-23 Ethiopia, Midterm Evaluation, October 2010 Save the Children 124