Our Programs

Strengthening Service Delivery in Ethiopia

Ethiopia

| 2023-2025

The Strengthening Service Delivery (SSD) project in Ethiopia, funded by the Gates Foundation, aimed to improve access to quality healthcare for women and children by addressing three persistent barriers: gaps in healthcare worker competency, weaknesses at service delivery points, and limited availability of essential supplies and commodities. Together, these challenges contributed to low coverage of family planning; maternal, newborn, and child health and nutrition services; and immunization coverage.

The SSD project’s goal was to reduce maternal, newborn, youth and child death through improved uptake of family planning and maternal, newborn and child health and nutrition (MNCH-N) at the point of service delivery through healthcare workers’ competency development, last mile supply delivery, and implementation of integrated service delivery of selected high-impact proven interventions.

The project was funded by the Gates Foundation and operated at the health facility level in eight regions of Ethiopia (Amhara, Oromia, Sidama, Central Ethiopia, South Ethiopia and Southwest Ethiopia, Afar, and Somali) in close collaboration with John Snow, Inc., Ethiopian Midwives Association, Family Guidance Association of Ethiopia, inSupply Health, ThinkPlace, and additional local partners, including universities and development associations.

Over the past two decades, Ethiopia has made substantial progress in improving maternal and child health and expanding access to essential health services, although important gaps remain. According to the 2024–25 Ethiopia Demographic and Health Survey (EDHS), the maternal mortality ratio is estimated at 141 deaths per 100,000 live births. Under-five mortality declined from 166 deaths per 1,000 live births in 2000 to 51 in 2024–25, while neonatal mortality declined from 49 to 25 deaths per 1,000 live births. Use of maternal health services has also improved: 78% of women received ANC from a skilled provider and 62% of births occurred in health facilities, although only 53% completed four or more ANC contacts and 19% completed eight or more.

Progress in other areas has been less consistent. Modern contraceptive use among currently married women increased from 6% in 2000 to 35% in 2016 but remained at 35% in 2024–25, indicating recent stagnation, while 15% of married women continue to have an unmet need for family planning.

Child nutrition and immunization also remain major concerns: 40% of children under five are stunted, while only 30% of children aged 12–23 months received all basic vaccinations and 21% were fully vaccinated according to the national schedule.

National averages also mask substantial geographic inequalities. Modern contraceptive use among currently married women ranges from only 2% in Somali and 9% in Afar to 54% in South West Ethiopia and 56% in Sidama, compared with a national average of 35%. Skilled ANC coverage similarly ranges from 35% in Somali to 98% in Addis Ababa. These disparities, together with persistent gaps in family planning, nutrition, immunization, and continuity of maternal care, highlight the need for equity-focused and context-specific FP/RMNCAH-N programming, particularly for underserved, rural, pastoralist, and conflict-affected populations.

There are also gaps between the national average and regions in maternal health. For instance, in Afar and Somali only 32.5% and 23.3% of women give birth in a health facility, respectively, which was lower than the national average of 47.5%; whereas Oromia and SNNP regions are aligned with the national average. Similar gaps between national averages and Afar and Somali regions—are found in the rate of skilled birth attendance number of ANC visits, postnatal care, and basic vaccination. The percentage of pregnant women taking iron supplements for 90 days or more also remains extremely low across Ethiopia at 11% (DHS 2019).

The increasing digital interconnectedness and the emerging user-friendly and cost-effective digital learning platforms are easing the barriers to reaching an unlimited audience at a distance for many academic activities, including health training. The Ministry of Health (MOH) has also emphasized innovation and technology as key guiding principles in its human resources for health development strategy. Cost-effective competency-based training and a mentorship delivery system are also prioritized within the MOH human resource development, including e-learning platforms and other training delivering modalities through an integrated, innovative, and comprehensive approach that will be appropriate in the Ethiopian settings.

Commodity security also remains a challenge for the Ethiopian health system, where stockouts of medicines, medical supplies, and equipment are caused by chronic supply chain gaps. According to the national health facility assessment of commodities and services, the “no stock out” status of at least three modern contraceptive methods in health facilities in Ethiopia is 63%.

EngenderHealth, together with consortium partners, and in consultation with MOH, worked to support the government to optimize existing best practices, promising solutions and tested new high-impact practices and innovative interventions that helped improve healthcare workers’ competency, last mile supplies delivery, and delivery of integrated services at the primary healthcare level.

The key interventions for this program developed healthcare competency, improving the last-mile supply chain, and improving integrated high-impact interventions. Our implementation also followed an integrated approach to strengthen national efforts in human resources for health and to accelerate high-impact practices at the micro-level in high-need settings.

Under the SSD project, EngenderHealth provided:

Technical and program leadership on the design, testing, endorsement, and dissemination of blended training packages on family planning for midlevel healthcare workers as per the national standards, strengthening provider competency to deliver quality, person centered care.
Technical and research leadership in the development, testing, and optimization of an integrated model of care linking family planning, nutrition, and immunization services. Through implementation research conducted in 20 Health Facilities, EngenderHealth generated evidence on practical approached to integrated service delivery and contributed to the development of a scalable model for Ethiopia’s primary healthcare system.
Technical and program leadership in gender sustainability, ensuring that gender intentional approaches were integrated throughout the SSD project implementation through GYSI Analysis, capacity strengthening, application of EngenderHealth’s GYSI framework and monitoring approaches, and promotion of equitable access to FP- MNCH-N information and services. The project integrated a gender, youth, and social inclusion (GYSI) lens into all activities to support project stakeholders to reflect, challenge, and change personal gender-, youth-, and social marginalization-related biases and beliefs that impact access to.

The key achievements of the project are presented by primary outcomes as follows:

Enhanced provider competencies to deliver quality person-centered care.

Built capacity of 150 providers through blended learning approaches, onsite mentorship, supportive supervision, and continuous performance review.
Procured and distributed critical medical equipment, anatomical simulation models, and 6,000 family planning kits with a combined value of over USD 161,000 to improve facility readiness, expanded competency-based training capacity, and supported the continuity and quality of family planning services at priority facilities nationwide.

Strengthened integrated service delivery structures and quality processes.

The project successfully developed an optimized Model of Care across 20 health facilities to integrate PPFP, PAFP, immunization, and nutrition within the RMNCH-N continuum.

Between October 2025 and February 2026:

The proportion of clients receiving family planning services through integrated delivery within nutrition platforms increased from 25.4% to 47.5%.
The proportion of mothers receiving family planning counseling during EPI visits increased from 4.7% to 29.0%.
The proportion of clients linked to family planning services through EPI platforms increased from 0% to 12.5%.
The proportion of clients receiving nutrition counseling during EPI visits increased from 9.4% to 28.9%.
The proportion of clients receiving nutrition counseling within family planning services increased from 23.8% to 29.1%,
Satisfaction increased from 73.8% at baseline to 95.7% at endline.

Lessons learned

Maximizing provider skills and genuine clinical behavior change requires moving away from isolated classroom training toward blended learning models—combining digital instruction and interactive practice with sustained, facility-based mentorship.
Successful service integration requires deliberate workflow redesign, provider engagement, functional referral systems, and continuous implementation support.
Regular review of implementation data, supervision findings, and stakeholder feedback enables timely adaptation and continuous improvement of integrated service delivery models.
Sustaining high-quality services requires embedding routine, standardized operational processes, and simplified data tools into daily health facility workflows.