Strengthening Service Delivery in Ethiopia
The SSD project’s goal is to reduce maternal, youth, and child/newborn death through improved uptake of FP-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.
This project is funded by the Bill & Melinda Gates Foundation and operates 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. (Prime), 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 achieved tremendous advances in making high-quality essential health services universally available, accessible, acceptable, and affordable. Maternal mortality declined from 871 per 100,000 live births in 2000 to 267 in 2020, under-five mortality rates declined by two-thirds, and neonatal deaths declined by approximately half in the same period (according to data from UNICEF). Modern contraceptive prevalence among married women increased from 14% in 2005 to 41% in 2019 and facility-based deliveries increased from 26% in 2016 to 48% in 2019 (according to data from the 2019 Ethiopia Mini Demographic and Health Survey). Child malnutrition has also decreased steadily since 2005, with more pregnant women attending antenatal care (ANC) visits (43%) and taking iron supplements, and the national immunization coverage for DPT3 and Measles has reached 62% and 59%, respectively. Despite this progress, Ethiopia remains among the countries with a high rate of maternal and child mortality and morbidity.
Key family planning, maternal, neonatal, child health, and nutrition (FP/RMNCAH-N) indicators show notable variation between national averages and regions. Modern contraceptive use varies from 38.9% in Oromia and 44.6% in Southern Nations, Nationalities, and Peoples’ Region (SNNPR), which were comparable with the national average, to just 3.4% in Afar and 12.7% in Somali, which were far lower than the national average of 40.5%, indicating stark geographic differences that require highly contextualized programming approaches. In Ethiopia, an estimated 4.5 million women of reproductive age have an unmet need for modern contraception. The unmet need for contraception varies across regions and it is 28.9%, 20.8%, 17.2%, 12.6% in Oromia, SNNPR, Afar, and Somali regions, respectively (according to Guttmacher).
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, will work to support the government to optimize existing best practices, promising solutions and test new high-impact practices and innovative interventions that help improve healthcare workers’ competency, last mile supplies delivery, and delivery of integrated services at the primary healthcare level.
The key interventions for this program are developing healthcare competency, improving the last-mile supply chain, and improving integrated high-impact interventions. Our implementation will also follow 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 will have the following roles:
- 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.
- Technical and program leadership in the design and implementation research and use evidence to test FP integrated services provision within the RMNCH-N continuum of care, building on our previous work on FP integration in Ethiopia.
- Technical and program leadership in gender sustainability, ensuring that gender intentional approaches are integrated throughout the SSD project. We will lead program design activities for gender integration, implement EngenderHealth gender, youth, and social inclusion (GYSI) training, conduct GYSI analysis using the GYSI framework and implement our GYSI marker for project monitoring. This project will integrate a 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 FP-MNCH-N information and services.
The following are three expected primary outcomes of this project:
- Enhanced provider competencies to deliver quality person-centered care
- Strengthened integrated service delivery structures and quality processes
- Improved last-mile service supply and commodity delivery, including vaccines
