Overview of COMMUNITY ENGAGEMENT FOR MATERNAL HEALTH SERVICES ETHIOPIAN EXPERIENCE Tadesse Ketema MD,MPH Maternal Child Health Advisor,MOH

1. – CONTEXT In Ethiopia 83.6 % lives in rural areas, and has high level of pregnancy as well as maternal and child morbidity and mortality including MTCT On the other hand most health care facilities were concentrated in urban areas To address this challenge the Government has designed and implemented the health extension program since 2005.

1.1 The Government targets for 2015 Of PMTCT Provide ANC services to 90 % of pregnant women Ensure all women are attended at delivery (62% by skilled attendant and 38% by HEWs) Provide ARV prophylaxis to 90% of HIV positive pregnant women Reduce national incidence of HIV infection by 50%

1.2 The major challenges to PMTCT to be addressed Limited expansion of PMTCT services; Inadequate use of PMTCT service where it is available Limited access to and utilization of early infant diagnosis low percentage of deliveries attended at health institutions Attitude of health workers Weak community-health facility referral linkages Poor male partner involvement Slow roll out of HMIS and poor recording and reporting practices

1.3 Rationale for community engagement need for MNCH/ PMTCT In 2003 EFY (July 2010 to June 2011), 82% of women accessed ANC services at least once As of July 2011, PMTCT services were available in health facilities where only 54% of women attended for ANC. This calls for expansion of PMTCT services to avail it to all women who have contact with the health service for ANC.

NB:The ANC coverage report on the graph Source :Hapco Report,June 2010

Rationale for community engagement cnd... Of women who attended ANC clinics at health facilities that are providing PMTCT services in 2003 EFY (2010/2011), more than 300, 000 of them (25%) were not tested ARV prophylaxis was provided for 8365 (40%) of women identified as HIV + at these facilities 4945 (24%) of their new-borns has got ARV There is a 23% drop out from counselling to testing and 60% from identification to provision of ARV prophylaxis to HIV positive pregnant women

Rationale for community engagement contd... These missed opportunities can be avoided with improved through engaging community and improving quality of care provided to retain women in PMTCT services including  linkage to community systems to initiate services and track cases lost to follow up  close monitoring of these activities  local data utilization for timely identification of gaps

2. Health Extension Program 2.1. General Objective: Improving the health of the population through disease prevention focused expansion, and family and community centered equitable health services 2.2. Specific Objectives: To enable community members to take greater responsibility for their health, have better decision‐making on health issues, and improve and maintain their own health; Enhancing community consciousness in strengthening disease prevention activities and improving health outcomes;

3.E ffective community engagement Health Extension and Development Army A health post built in each kebele through community participation, to serve an average of 5,000 people in family and community focused disease prevention and health promotion services. A health center is also organized to support a cluster of five health posts; it serves approximately 25,000 people on average. Around 30 thousand HEWS trained and deployed in around 15,000 health posts

HEWS are tenth grade complete and trained for a year on 16 packages of the health extension program One health post is staffed with two health extension workers who are all females Progress has been registered in reducing under five child mortality rate, increasing number and use of latrines, increasing family planning and vaccination coverage as well as significant decline in death and disabilities due to malaria ANC coverage is tripled and reach to 82% since 2005 and FP utilization has also shown a dramatic improvement

Level of Intervention PriorityActivity HouseholdHouseholds with pregnant women; mothers who delivered recently and infants; Households with persons having chronic health problems; and Households with satisfactory result in implementing the health extension packages. Family planning, antenatal care, postnatal care and immunization services; Provision of basic health care services during household visits; CommunityConveying health education and Health services at the community level; Health extension workers will deliver services to members of the community in outreach program via a cluster of gotts/sub village; In delivering the health extension program packages it is essential to use community social networks (Idir, Ekub, etc), Associations (women’s, youth and farmers associations), religious institutions and Government structures (for example agricultural development stations). Institutional LevelIn delivering the health extension program packages it is essential to use community social networks (Idir, Ekub, etc), Associations (women’s, youth and farmers associations), religious institutions and Government structures (for example agricultural development stations). Deliver health education and services at youth centers; Make schools models of implementation of the health extension packages and educate students; and Organize or use existing clubs in the school to train students on important health issues;

LevelActivity Health Post  Provide integrated community case management (ICCM) for childhood illnesses;  Control and register the temperature for vaccine/maintain cold chains;  Give vaccination services;  Provide family planning services;  Provide ante‐natal and post natal care;  Identify children, pregnant and breast feeding mothers with nutritional deficiencies and give nutritional counseling;  Follow‐up, supportive supervision and assessment/evaluation of quality and transparency of the activities being implemented by the one‐to‐five networks;  Prioritizing households with low performance in implementing the package and support them in all the health extension packages that are relevant to them;  Providing health education; and  Support and encourage model households to maintain their progress.  Organization, follow up, supportive supervision and evaluation of the one‐to‐five networks and Development teams; and  Organize and conduct regular meetings every two weeks to evaluate the performance of the Development teams.

Model Family Training Model Household Training is a training program conducted by the health extension workers and leaders of one‐to‐five networks on all health extension packages

4. The Role of the MoH in Supporting The Program Strengthening primary health care unit (PHCU); Preparing guidelines and other essential documents/materials that support the health extension program and ensure its proper implementation; Strengthening collaboration and improving communication among different sector ministries at the federal level, Regional Councils, Regional Health Bureaus as well as development partners for the successful implementation of the health extension program;

Close follow up and encourage the sharing of information in promoting collaboration and networking; Evaluate the implementation of the program Acknowledge and reward those health extension workers for their outstanding performance Design and implement integrated supportive supervision activities; Develop standards for the in‐service integrated refresher training, further education, career development structure for the health extension workers and closely follow‐up for its implementation;

5.Challenges and Recommendations to the program ChallengeStrategies for Overcoming Barriers The health extension program performance and impact did not have the expected high velocity and quality since it was managed in a campaign form, and lacked the strategic leadership required to coordinate and organize community level activities  Establish and use the health development army  Strengthen referral linkage and  Strengthen urban HEW implementation The health extension workers alone may not be sufficient to implementing all the packages in the health extension program. Hence, it appeared to be essential to organize community members in development teams and in one‐to‐five networks Weak Referral linkage as the rural Health extension workers are not mandated to do T & C but link for one ANC visit to Health Center  Organizing community members in health development army empowers the community in making decisions and owning the program.  This situation in turn accelerates the implementation of the program and improves the health of the community in a short period of time.  Strengthen the referral linkage within the PHCU

Thank you