Concept note of the Primary Health Care QOC activity.pdf

Quality of Care in Primary Health Care and Referral

Facilities Activity

CONCEPT PAPER

Submitted by the ECBH Project

Date: 1/22/2021

Country Context and Problem Statement 1

Activity Objective: 4

Results Areas 5

The QOC Activity Theory of Change: 5

Activity Description and Expected Results 6

Local Ownership and Sustainability Error! Bookmark not defined.

Choice of Instrument 14

Project Management Approach Error! Bookmark not defined.

Estimated Cost Error! Bookmark not defined.

Annexes: Error! Bookmark not defined.

Annex 1: Pictorial Result Framework 15

Annex 2: Approach for Targeted Technical Assistance 15

Annex 3: Additional LME and CLA Considerations 16

Illustrative indicators 17

A. Country Context and Problem Statement

Country Context:

Ethiopia has a population of 112 million of which over 80 percent are rural residents. The country has eleven regional states and two city administrations that are further divided into zones, woredas, and kebeles. The woreda (district) is the lowest independent administrative unit. Ethiopia’s health sector is decentralized, with the woreda managing the bulk of public health programming. Ethiopia is home to over 80 ethnic groups with diverse cultural, religious, and linguistic backgrounds.

Health context:

Ethiopia Service Delivery Context: Ethiopia’s 1993 Health Policy continues to provide the health system framework in emphasizing comprehensive primary health care (PHC), including disease prevention, health promotion, and rehabilitating disabilities1. The policy also mandates that the Ministry of Health (MOH) develop health infrastructure, health workforce, and service delivery systems. The fourth Health Sector Development Plan (HSDP)-IV, 2010/11-2014/15) introduced a three-tiered health care delivery system as depicted in the diagram below.

Primary health care level consists of a primary hospital, health centers (HC), and satellite health posts

(HP) which together are called Primary Health Care Unit (PHCU) and serve a catchment population of between 60,000 and 100,000 and are managed by district level health authorities. Secondary care is delivered by general hospitals with a catchment population of 1.5 million and overseen by regional health bureau. Tertiary care is provided by specialized hospitals with a catchment population of approximately 5 million people2 with regional and federal oversight. The referral network is embedded

1 Federal Democratic Republic of Ethiopia (FDRE). Health Policy of the Transitional Government of Ethiopia. Addis Ababa: FDRE;

1993.

2 World Health Organization (2015): Improving health systems efficiency: human resources for health reforms.Source:https://apps.who.int/iris/bitstream/handle/10665/187240/WHO_HIS_HGF_CaseStudy_15.6_eng.pdf;jsessionid=D40C92 E3C651C56B88DE44C3B00675AA?sequence=1#:~:tex t=HSDP%20IV%20has%20introduced%20a,by%20specialized%20hospitals%2

0(3). Accessed on April 10, 2021.

https://drive.google.com/file/d/1AfnAvacC2T-fvgj_OdPlqTH1wB75KhLC/view?usp=sharing https://drive.google.com/file/d/1AfnAvacC2T-fvgj_OdPlqTH1wB75KhLC/view?usp=sharing https://drive.google.com/file/d/1AfnAvacC2T-fvgj_OdPlqTH1wB75KhLC/view?usp=sharing https://apps.who.int/iris/bitstream/handle/10665/187240/WHO_HIS_HGF_CaseStudy_15.6_eng.pdf;jsessionid=D40C92E3C651C56B88DE44C3B00675AA?sequence=1#:~:text=HSDP%20IV%20has%20introduced%20a,by%20specialized%20hospitals%20(3) https://apps.who.int/iris/bitstream/handle/10665/187240/WHO_HIS_HGF_CaseStudy_15.6_eng.pdf;jsessionid=D40C92E3C651C56B88DE44C3B00675AA?sequence=1#:~:text=HSDP%20IV%20has%20introduced%20a,by%20specialized%20hospitals%20(3) https://apps.who.int/iris/bitstream/handle/10665/187240/WHO_HIS_HGF_CaseStudy_15.6_eng.pdf;jsessionid=D40C92E3C651C56B88DE44C3B00675AA?sequence=1#:~:text=HSDP%20IV%20has%20introduced%20a,by%20specialized%20hospitals%20(3) in the service delivery systems to link the health facilities within and across different tiers/levels of care.

The preventive, promotive, essential curative and rehabilitative health services are mainly provided at the PHCU, which is also where USAID has directed its investments over the past decades.

Ethiopia Health System Performance: The 2016 Ethiopia Demographic and Health Survey (EDHS)3 and the 2019 mini-DHS4 revealed tremendous progress in several health service access, delivery and outcome indicators at national level over the last 20 years. However, newborn mortality and nutrition indicators have stagnated. Moreover, there are significant disparities across regions and also different population groups that are buried under national aggregate reports. Generally, urban areas have better health outcomes than rural areas, but women, children, and adolescents living in urban slums appear to have less access to health services and consequently, suffer poor health outcomes. Comp ared to non‐ slum residents, those living in slums often face worse health outcomes in overall mortality, maternal and newborn morbidity and mortality, and child mortality as indicated by a study in Kenya that puts MMR in slums at 706 per 100,000 live births as compared to a national average of 488.56 Ensuring equitable access to quality healthcare for all Ethiopians is at the heart of a well performing health system7, and key for achieving sustainable development goals (SDG)8. This principle ideally should guide all investments in public and private health sectors to the benefit of Ethiopian citizens.

Global Definitions on Quality: Currently, there is no universally accepted definition of quality within the global health community. Health care providers, financers, purchasers, clients, and communities

(i.e., users of health services) have different perceptions regarding the quality of health care. Yet a standard definition would be critically important to measure, monitor and continuously improve the quality of health care. The US Institute of Medicine (IOM) issued the guiding definition “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”,9 which is generally accepted and applied10 for measurement, monitoring and improvement of quality of health care.

Berwick, D. et al aptly described in their 2018 article ‘Crossing the global quality chasm: improving health care worldwide’ that concerns of quality of healthcare exist in all health systems, regardless of any country's socio-economic and health sector development status. The authors also classified the difference between the desired and actual health services not as a simple gap but as a “chasm”. Among the key recommendations included in the report:

● redesigning person-centered healthcare system and improving the patient journey across the life course

● ensuring health system accountability to the service users

● addressing adverse impacts of corruption

● building health literacy in the community

3 EDHS. Central Statistical Agency [Ethiopia] and ORC Macro. Ethiopia Demographic and Health Survey (EDHS); 2016 4 Ethiopian Public Health Institute (EPHI) [Ethiopia] and ICF. 2019. Ethiopia Mini Demographic and Health Survey 2019: Key

Indicators. Rockville, Maryland, USA: EPHI and ICF.

5 AMDD-Urban-MNH-Report_July-20-2016-Final-Report

6 The effect of enhanced public-private partnerships on Maternal, Newborn and child Health Services and outcomes in Nairobi-Kenya the

PAMANECH quasi-experimental research protocol 7 Delivering quality health services: a global imperative for universal health coverage. Geneva: World Health Organization, Organisation for Economic Co-operation and Development, and The World Bank; 2018. Licence: CC BY-NC-SA 3.0 IGO 8United Nations, The 2030 Agenda for Sustainable Development,https://sdgs.un.org/goals 9 Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National

Academy Press; 2001 10 Ministry of Health (2016): Ethiopia National Health Care Quality Strategy (2016 -2020): Transforming the Quality of Health Care in

Ethiopia https://drive.google.com/file/d/1h13jf18IRQQkwYh8WWB0ybm2kugjDZS4/view?usp=sharing https://drive.google.com/file/d/1h13jf18IRQQkwYh8WWB0ybm2kugjDZS4/view?usp=sharing https://drive.google.com/file/d/1q6k-9woj09HODFPOsyy8lnN6f16S3a9V/view?usp=sharing https://drive.google.com/file/d/1q6k-9woj09HODFPOsyy8lnN6f16S3a9V/view?usp=sharing https://drive.google.com/file/d/1QrJBvI7I3gd4Z-YyyqKosCpIMZswd5YH/view?usp=sharing https://drive.google.com/file/d/1lU98V0RXUOlrhF19837MRAzo7HV63s4h/view?usp=sharing https://drive.google.com/file/d/1lU98V0RXUOlrhF19837MRAzo7HV63s4h/view?usp=sharing https://drive.google.com/file/d/1uYn4tRxMj4aCRvqo5CgEX5L7R9qnaJ4O/view?usp=sharing https://drive.google.com/file/d/1uYn4tRxMj4aCRvqo5CgEX5L7R9qnaJ4O/view?usp=sharing https://sdgs.un.org/goals https://sdgs.un.org/goals https://sdgs.un.org/goals https://drive.google.com/file/d/1PX0-0IpLNB6sS6nVVq9KcYhdX-WCvg_0/view?usp=sharing https://drive.google.com/file/d/1PX0-0IpLNB6sS6nVVq9KcYhdX-WCvg_0/view?usp=sharing https://drive.google.com/file/d/1pOJEvYxFMLYylMpXKJqtFqxZUVZevmvE/view?usp=sharing https://drive.google.com/file/d/1pOJEvYxFMLYylMpXKJqtFqxZUVZevmvE/view?usp=sharing

● integrating and coordinating the care

● strengthening public-private partnerships,

● learning and properly incorporate the informal care (self-care/family care) sector,

● creating a culture of learning and use opportunities of increase in availability of digital technologies11.

Quality Improvement Efforts in Ethiopia: As clearly stipulated in Ethiopia’s two health sector transformation plans (HSTP-I, 2015-2020 and II, 2021-2025), quality and equity in healthcare, and particularly at the PHC level, are within the top priorities for the country. Improving these two essential elements of health service at lower system levels requires creating high-performing PHCUs, engaging the community in service delivery, and consistently improving clinical care outcomes. This inturn requires competent and motivated care providers, managers and leaders at lower and referral facilities, and management structures.

Based on the HSTP-I priorities and transformation agenda, Ethiopia developed and launched a National Healthcare Quality Strategy (2016-2020) to guide its planning and implementation of national healthcare quality improvement practices. The National HealthCare Quality Strategy (NQS) defined quality as a “comprehensive care that is measurably safe, effective, patient-centered, and uniformly delivered in a timely way that is affordable to the Ethiopian population and appropriately utilizes resources and services efficiently”12. The NQS prioritized maternal, newborn and child health (MNCH), nutrition, communicable and non-communicable diseases and clinical and surgical services. Building on the NQS, several quality improvement initiatives were developed and implemented including MNCH Quality of Care, Saving Lives through Safe Surgery (SaLTS), and the Learning Health Facility 13 to mention a few.

However, these initiatives have narrowly improved QOC, only within their respective technical areas of focus and associated facilities; consequently, such limited coverage resulted in low nationwide impact.

As a result, assessment of NQS implementation showed only 34 of the 54 interventions (64%) in the NQS were initiated by 2020.

Institutionalizing QOC interventions requires adequately resourced and empowered structures to facilitate effective planning and implementation of initiatives, and coordination amongst technical units at different levels and key stakeholders.14The NQS development spotlighted role confusion and limited capacity and practices of coordination among the MOH's multiple governance units, which predictably affected the NQS's uniform adoption and content application across health priorities.

The NQS was comprehensive; however, its content did not sufficiently highlight points of flexibility within its recommendations that can best respond to emerging and evolving needs. The recently revised and updated national quality and safety strategy is anticipated to address most of these issues and will hopefully inform the resulting implementation guidelines. Ethiopia's health system continues to strive for an efficient, coordinated referral system linking facilities through clear, transparent communication, coordinated client-centered services, and documented patient tracking within referrals across facilities.

Ethiopia captures several Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) coverage indicators through its Health Management Information System (HMIS), which has greatly

11 Berwick D, Snair M, Nishtar S. Crossing the global health care quality chasm: a key component of universal heal th coverage. Jama.

2018 Oct 2;320(13):1317-8.

12 Federal Democratic Republic of Ethiopia Ministry of Health. Ethiopian National Health Care Quality Strategy, 2016 -2020.

13 Ministry of Health (2019): Ethiopian Health Care Quality Bulletin. Vol 1, May 2019 14Ministry of Health (2020): Review of HSTP-I achievements (situation analysis) for Second Health Sector Transformation Plan (HSTP) https://drive.google.com/file/d/1PX0-0IpLNB6sS6nVVq9KcYhdX-WCvg_0/view?usp=sharing https://drive.google.com/file/d/1PX0-0IpLNB6sS6nVVq9KcYhdX-WCvg_0/view?usp=sharing https://drive.google.com/file/d/1pOJEvYxFMLYylMpXKJqtFqxZUVZevmvE/view?usp=sharing https://drive.google.com/file/d/1pOJEvYxFMLYylMpXKJqtFqxZUVZevmvE/view?usp=sharing https://www.healthynewbornnetwork.org/hnn-content/uploads/Final-QualityBulletin_May2019-for-Print-1.pdf https://www.healthynewbornnetwork.org/hnn-content/uploads/Final-QualityBulletin_May2019-for-Print-1.pdf https://docs.google.com/document/d/1kNZ6ZK_xbTV3DcP7dQvClCaxcvoRBi9-/edit?usp=sharing&ouid=102697734792606518252&rtpof=true&sd=true improved data analysis and use to inform decision making and policy development. Yet, indicators assessing levels of quality within such care are mostly absent.

The Northern Ethiopia conflict that started in Nov 2020 and is still continuing has resulted in the destruction of several key infrastructure including health facilities resulting in limited health access to millions of people in Tigray, Amhara and Afar. This would require a concerted effort to bring back the health system in these regions to the level before the conflict and ensure delivery of quality RMNCH services.

Problem Statement

Ethiopia has developed service quality standards for maternal and newborn health services; however, several challenges have impeded the implementation of these standards. There is poor governance and coordination within PHCUs and referral facilities as well as at various levels of the health system that are responsible for quality improvement to tackle the QOC bottlenecks.

The maternal, newborn and child health service quality standards developed by MOH were not widely used due to several factors including inadequate understanding of healthcare quality concept and limited practices, weak organization and delivery of health care services, communities’ preference for secondary and tertiary level care and bypassing the primary healthcare level. Additionally, shortage of competent and motivated care providers, essential drugs, medical equipment and technologies; poor infrastructure, weak referral and service integration across components within and along the continuum of care, and weak data use for improvement were identified. Poor infrastructure including insufficient power with unreliable electric supply, lack of consistent water supply and poor sanitary facilities15,16, and weak internet connectivity are other impediments for quality improvement efforts and implementation of

NQS.

Thousands of health facilities have been damaged and looted in the war affected areas and access to health care for the population in this conflict affected areas has become a huge challenge. Per the MOH’s report in December 2021, over 2800 health facilities (40 hospitals, 453 health centers, 1850 health posts, and 466 private health facilities) are damaged in the Amhara region alone. There is a plan by the health offices and partners to assess the magnitude of damage to these health facilities and it is expected that this will provide detailed information on the degree of damage and the need in each of the health facilities. In Tigray, per a joint supervision finding carried out by USAID health partners in August, 2021, in about 79% of the health facilities assessed, health workers have returned to the HFs and resumed services. However, in 26% of them, shortage of medical supplies and furniture was reported. Many of the residents in the conflict affected areas including health care providers have fled their homes and are currently in internally displaced people (IDP) sites where they face challenges in accessing esse ntial health services. Those who stayed in the conflict affected areas have limited or no access to healthcare as most of the health facilities that used to serve are now damaged or looted and health care service provision is discontinued.

B. Activity Objective:

The purpose of the activity is to build capacity of urban and peri-urban PHCUs and referral health facilities in planning and delivering of client-centered quality reproductive, maternal, newborn, child, and adolescent health (RMNCAH) services. This activity will improve RMNCAH status of women, 15 Ethiopia Service Availability and readiness Assessment (SARA), 2018 16 FMOH. Review of National Health Care Quality Strategy (2016 – 2020), Draft report, April 2020 https://drive.google.com/file/d/1XAXRXbY8eFQurupH-BH9mbdC4tZvGdpV/view?usp=sharing https://docs.google.com/document/d/1_jWO34pS9kfWGQ1puhe3VZuFWheveWP2/edit?usp=sharing&ouid=102697734792606518252&rtpof=true&sd=true adolescent girls and children by increasing readiness of the health facilities and delivery of quality, patient-centered RMNCAH care by increasing competency and performance of healthcare providers and managers, strengthening systems for feedback and accountability and enhancing community participation thereby increasing client satisfaction and service utilization and ultimately prevent maternal and child mortality. The activity will also support restoration of health services in conflict affected areas by rehabilitation and equipping of damaged facilities.

Results Areas17

IR. 1 Readiness for and delivery of Quality RMNACH Services Improved SubIR 1.1. Health facilities are capable of fulfilling all required inputs to deliver quality RMNCH services.

SubIR 1.2: Competency of healthcare providers improved18 SubIR 1.3. Delivery of client- centered care through continuous quality improvement (CQI) ensured SubIR 1.4. Referral systems and networks are functional and coordinated

IR 2. Management and Accountability for Quality Service Delivery Strengthened

SubIR 2.1. Structure19 and Systems20 for Healthcare Quality Improved SubIR 2.2. Generation and use of evidence to improve Quality of RMNCAH services increased

SubIR 2.3. Community representation and engagement on CQI at health facilities increased

IR 3. Health services restored in health facilities in conflict affected areas

SubIR 3.1. Select damaged health facilities are rehabilitated SubIR 3.2. Essential health service provision restored in rehabilitated facilities SubIR 3.3.QOC systems established and maintained in health facilities affected by the conflict

The QOC Activity Theory of Change:

IF the readiness of health facilities for delivery of quality RMNACH service is improved; and

IF management and accountability for quality service delivery increased; and

IF health services restored in health facilities in conflict affected areas.

Assuming that, PHCUs and referral facilities consistently utilize their increased capacity to continuously improve QOC of RMNCH services.

Resources to resolve bottlenecks for RMNCAH quality services are availed by and for the facilities.

Other USG and non-USG-supported health system activities are successful in co-leveraging their investments for a well-functioning health system; and

17 see annex1 for result framework 18 Service Provider Capacity (competency, skill, compliance), motivation and performance Strengthened to Align to National Clini cal

Protocols (Quality, Child Health, Newborn Health, Maternal Health, FP/SRH) 19 Structure stands for unit or team in-charge of quality of healthcare 20 System stands for: QoC standards, guidelines, data management systems, plan -performance review and feedback system, Accountability mechanism etc

Peace is restored in the conflict affected areas

THEN the quality improvement efforts will be sustained; and the quality of RMNCAH services will be enhanced for improved client satisfaction and health services utilization leading to improved health outcomes.

C. Activity Description and Expected Results

This activity falls under USAID/Ethiopia’s Development Objective 4 (DO4) that aims to advance gender-equitable essential service outcomes and directly contributes to its two health projects, Empowered Communities for Better Health (ECBH) and the Health System Strengthening (HSS) Projects. ECBH is the primary/home project for this activity.

The activity will contribute to two intermediate results (IR) under DO4, IR 4.4: “Utilization of quality health and nutrition services increased;” and IR 4.5: “Health and nutrition systems strengthened for greater self-reliance”. The activity directly contributes to IR 3 of the ECBH Project which aims to improve quality of health services at primary level health facilities, particularly Sub-IR 3.2 that aims to increase capacity of primary-level health facilities and woreda health officials to deliver optimal quality of health services to the community. The activity will also contribute to IR 2 of HSS, improved quality of essential services especially IR 2.1 strengthened adherence to service delivery standards and improved clinical oversight.

The Activity will build on the gains of the RMNCAH flagship activity of TPHC and will be implemented in seven regions: Tigray, Amhara, Benishangul Gumuz, Oromia, Sidama, South Western Ethiopia and

SNNPR. Final decisions on geographic selection will be made after a thorough review of relevant data and receipt of post-conflict assessments. Besides, Secondary cities aligned with the Alternative Growth poles21 will be prioritized for targeting by the activity.

The activity will have integration and layering with ongoing and new activities under the HSS and

ECBH projects including Empowered Communities, social and behavior change communication

(SBCH), Supply chain, Health Workforce Improvement Program (HWIP), Health Financing

Improvement Program (HFIP), Multisectoral Nutrition, and Digital Health Activity etc and the WASH project to leverage support for facility access to ensure inputs and systems are strengthened as well as access to WASH infrastructure as well as technical assistance. The activity will be flexible to identify, assess and support responses to any man made or natural disasters including disease outbreaks, drought, conflict etc. that affect the health of the target population to protect the gains in its development work and save lives of mothers and children. The activity will have specific agreed upon criteria to ensure the assistance provided is tailor made to the need of the facilities and the gaps they have. Facilities will put under four tiers based on their status at the start of the activity with Tier 0 being facilities in conflict affected geographies; Tier 1 which did not have previous USAID support, high -volume facility, high maternal and or newborn/child death rates OR other related RMNACH indicators; Tier 2 historically

USAID supported ones and Tier 3 facilities at a level of network of excellence (See Annex 2). For conflict affected areas as well as others the activity will leverage additional resources and technical expertise to ensure efficient utilization of limited resources.

21 Alternate Growth pole final report, June 2021 https://docs.google.com/document/d/1u-2HpeZ5d9WdPDDQ9oIde6JPk6FC0JlI5oGmtE_-HhE/edit?usp=sharing

IR. 1 Readiness for and delivery of Quality of RMNCAH Service Improved

Health facility readiness refers to the capacity of health facilities to provide a specific service to the public, and measured through the presence of tracer items. The tracer items to measure health facility readiness include infrastructure and basic amenities22, availability of trained health care providers and managers, equipment, and essential supplies, medicines and diagnostic capacities to provide basic health-care interventions23,24 According to Ethiopia's Service Availability and Readiness Assessment

(SARA, 2016), only 7 percent of the facilities have fulfilled all the tracer items for readiness to provide family planning services, and an average availability of the 8 tracer items is 64 percent. In addition, the availability of at least one trained staff on family planning was observed in less than 60 percent of health facilities. The gender mix of health facility staff is also unbalanced.

Sub IR 1.1: Health facilities fulfill all required inputs for delivery of quality RMNCAH services.

This activity will ensure facilities’ capacity to plan and mobilize stakeholders and resources that can support availability of essential amenities and inputs to deliver sustainable quality RMNCAH serv ices.

Expected results

● Facilities are able to avail basic amenities, equipment, essential medicine and diagnostic capacity

● Capacity for installation, management and equipment maintenance increased

● Capacity of health facilities for supply chain functions [forecasting, projection, planning, requesting/procurement, and monitoring and reporting stock level etc] for essential medicine and diagnostics improved

Sub IR 1.2. Competency of healthcare providers in RMNCAH improved

This sub-result aims to ensure facilities, especially high burden urban and peri urban PHCUs and referral facilities including private health facilities, adopt and institutionalize use of established RMNCAH standards to improve and sustain QOC across service delivery units to reduce maternal and child mortality.

Expected results

● HWs’ capacity on RMNCAH QOC standards is built

● HWs provided supervision, mentorship and technical support to adopt and use the QOC standards for RMNCAH at health facilities

● Improved provision of RMNCAH services as per the national standards

Sub IR 1.3. Delivery of Client Centered Care through Continuous Quality Improvement (CQI) ensured

Ensuring the voice of communities and clients heard through collecting and integrating feedback from clients and communities is important in improving QoC and building trust between healthcare providers and users. Gender and youth sensitive service provision has a high impact in ensuring better

22 Basic amenities assessed based on the availability of the following tracer items: power (grid or generator), communication equipment, consultation room, improved water source, adequate sanitation faci lities, and computer with internet access, and emergency transportation 23 Ministry of Health (2017): ETHIOPIA Services Availability and Readiness Assessm ent 2016; Comprehensive Report, January 2017.

24 Manu et al (2018): Assessment of facility readiness for implementing the WHO/UNICEF standards for improvin g quality of maternal and newborn care in health facilities – experiences from UNICEF’s implementation in three countries of South Asia and sub -Saharan

Africa. BMC Health Services Research (2018) 18:531 https://drive.google.com/file/d/1XAXRXbY8eFQurupH-BH9mbdC4tZvGdpV/view?usp=sharing https://drive.google.com/file/d/1gW-hcuJKBcy0sXZNUQAJ3kIalVnmHVxa/view?usp=sharing utilization of services.

● Functionality of QI/Performance Management Teams in health facilities including private health facilities improved

● Improved functionality of Patient Care/Advocate Feedback Platform (tools, forums, operations) for delivery of quality RMNCAH services

● Improved Awareness and solution by Provider and Manager to client Feedback

● Improved Youth and women friendly service provision

● Health facilities consistently score Green (commendable score) in the national QOC standard measures

Sub IR 1.4. Referral Systems and Networks are Functional and coordinated

The activity will support a streamlined, bi-directional referral system to facilitate efficient referral pathways across primary, secondary and tertiary levels of the health system and QOC in higher level facilities including private health facilities for better RMNCAH outcomes.

Expected Results

● Seamless and effective25 cross-directional referral networks for RMNCAH services across communities, PHCUs and referral facilities including private health facilities in place

● Established referral audit / accountability system for documentation, monitoring and evaluation of patient referral protocol implementation and end patient outcomes

● Critical patients are provided with the appropriate care by qualified and experienced team while being transported safely and efficiently

● Referral service provision is women and child friendly

IR 2. Management and Accountability for Quality Service Delivery Increased

High-quality RMNCAH health services are at optimal performance when such services are organized in structure and function with highly skilled leaders, managers and staff. Such organization within service delivery ensures local ownership and a client-centered service model grounded on evidence-based technical and operational standards.

Sub IR 2.1. Structure and Systems for Healthcare Quality Improved

High quality RMNCAH services receive optimum focus when quality of care is integrated into how these services are organized, managed, and monitored within the facility structure and processes. With strong leadership and management support, quality oversight structures ensure consistent review and troubleshooting of essential service delivery components for evidence-based, technically sound and client-centered health services.

25 patients get the required assessment and determination for referral, counseled adequately about to accept referral and their referral to the the referral facility done timely to get the best care possible and the referring facility gets the full information abou t the progress and any follow up need after that

Expected results:

Leadership capacity26 of managers of districts, PHCU and referral facilities including private health facilities improved.

● Improved effective monitoring of quality standard in addition to coverage of services by health facility leadership.

● QOC units at PHCU and referral facilities established/strengthened to fulf il mandates; and

● Inter-department coordination within PHCUs and referral facilities including private health facilities strengthened to improve QOC

● Improved participation of Women health workers in leadership roles

Sub IR 2.2. Generation and Use of Evidence to improve Quality of RMNCAH Increased

Availability and use of timely quality data are key for evidence-informed decision making in planning of all aspects of sustainable country-led quality improvement and management initiatives.

The activity will closely work with various stakeholders to improve quality measurement and use of data for QOC and strengthen the quality of RMNCAH services. The activity will promote consistent data analysis and utilization of existing data systems, e.g., HMIS/DHIS2, to support quality improvement initiatives and other cross-learning mechanisms that can accelerate health care improvements at PHCUs and referral facilities.

Expected Results:

● Capacity of the quality improvement committees at PHCUs and referral facilities including private health facilities on evidence generation and data use for decision making improved.

● Facility-level platform to coordinate evidence synthesis, research uptake and utilization for

QOC programming established/strengthened

● Data systems at service delivery points and districts (HMIS/DHIS2, eCHIS, EMR, LMIS, etc.)

strengthened to inform quality improvement/ management initiatives.

Sub IR 2.3. Community representation and engagement on CQI at health facilities increased

Community engagement for responsible stewardship is critical to improved accountability, sustainability and to addressing the increasing demand for quality care.27

● Increased proportion of health facility management committees with community member representation (particularly females);

● Community-facility platforms effectively assess and address client/community feedback

● Community-health facility interface platforms utilized well for QoC;

● Increased patient satisfaction with the services in the PHCUs and referral facilities

IR 3. Health services restored in health facilities in conflict affected areas

26 Leadership capacity: One’s individual knowledge, skills and abilities to manage people and resources ef fectively (to meet the results outlined in this concept note include improved health outcomes, no stock-out, etc) as per X standar 27 Wereta, T., Betemariam, W., Karim, A.M. et al. Effects of a participatory community quality improvement strategy on improving household and provider health care behaviors and practices: a propensity score analysis. BMC Pregnancy Childbirth 18, 364 (2018).

https://doi.org/10.1186/s12884-018-1977-9 https://doi.org/10.1186/s12884-018-1977-9 https://doi.org/10.1186/s12884-018-1977-9 https://doi.org/10.1186/s12884-018-1977-9 https://doi.org/10.1186/s12884-018-1977-9 https://doi.org/10.1186/s12884-018-1977-9 https://doi.org/10.1186/s12884-018-1977-9 https://doi.org/10.1186/s12884-018-1977-9

Thousands of health facilities have been damaged and looted in the war affected areas and access to health care for the population in this conflict affected areas has become a huge challenge. This activity will rehabilitate selected health facilities in areas affected by the war and support restoration of health service provision. In addition, the activity will work towards ensuring the health services provided in these facilities are of optimum quality by establishing and strengthening systems for continuous quality improvement.

Sub IR 3.1. Selected Damaged Health Facilities are Rehabilitated

The activity will rehabilitate selected health facilities in conflict affected areas of Amhara and Tigray regions in woredas where this activity will be operating as per national standards.

Expected Results

● The selected health facilities are fully renovated including electrification (solar panels) and water supply in limited facilities

● Renovated facilities have strong maintenance plan that would help in sustainable infrastructure management

Sub-IR 3.2. Essential health service provision restored in rehabilitated facilities

As health facilities have been damaged and all that was in them was looted and damaged health services are interrupted.

This sub-IR aims at supporting the resuming of essential health services in the renovated health facilities including RMNCH services.

Expected Results

● The right mix of health workers in terms of gender and profession are deployed and supported to resume provision of health services in the renovated health facilities

● Renovated health facilities are stocked with basic medical equipment, supplies, drugs and HF furniture to resume health care service provision

● Community mobilized to utilize health care services from these renovated health facilities

Sub IR 3.3. QOC systems established and maintained in health facilities affected by the conflict

Once health care service provision in the renovated health facilities is resumed, there is a need to ensure continued quality improvement procedures and processes. This sub-IR aims at ensuring CQI systems are instituted and sustained in these renovated health facilities.

Expected Results

● Leadership and management capacity for quality of care at the renovated health facilities improved

● Health workers competency for quality of care at the renovated health facilities improved

● Referral systems and network in the renovated health facilities are instituted and strengthened

● Health facilities are able to fulfil the QOC standards to their level

D. Local Ownership and Sustainability

The Quality-of-Care activity focuses on establishing and strengthening a system for standardization of RMNCAH services in the public and private health systems utilizing existing GOE structures. The activity will work to ensure PHCUs and referral facilities own the standardization of services, provision of these services as per the standard and use existing monitoring mechanisms to ensure that they are adhered to. Also, this activity will support a stronger coordination among RMNCAH and other units in facilities to ensure better ownership and sustained results. These approaches address the major problem that has been identified as a major area of concern in the HSTP as well as the evaluation of the National Health Service Quality Strategy. Besides, the activity ensures strong collaboration among various health facilities through mentorship and collaborative programs and will ensure strong partnership with educational establishments in each region. These collaboration and partnership will ensure mobilization of technical support to the facilities; sustain stronger referral systems as well as institutionalized normative change on how to provide quality care. The activity will also help facilities to identify areas of need, mobilize resources to cover these gaps in a sustainable manner. The activity will support innovative and locally led interventions like the family health team approach and utilize Private Health facilities network and associations to enroll private health facilities for this activity.

E. Summary of Conclusion and Analyses

The summary and conclusion of our analysis below is based on analysis of findings from the multiple consultations done with various relevant stakeholders including relevant FMOH people, Regional Health Bureaus, Implementing Partners etc. We also have made a systematic review of key international and nationally seasoned evidence on the field and performance and evaluation reports. A more detailed summary of the findings and the conclusion of the analysis is annexed.

The Lancet Global Health Commission: The Lancet Quality Commission report identified that the care people receive is often inadequate, and poor-quality care and that the most vulnerable populations are faring the worst. It stated that high-quality health systems could save over 8 million lives each year in LMICs. It recommends that health systems should measure and report what matters most to people, such as competent care, user experience, health outcomes, and confidence in the system. To address the scale and range of quality deficits the commission documented, reforming the foundations of the health system is required. The Commission endorsed four universal actions to raise quality across the health system. First, health system leaders need to govern for quality by adopting a shared vision of quality care, a clear quality strategy, strong regulation, and continuous learning. Second, countries should redesign service delivery to maximize health outcomes rather than geographical access to services alone.

Third, countries should transform the health workforce by adopting competency-based clinical education, introducing training in ethics and respectful care, and better supporting and respecting all workers to deliver the best care possible. Fourth, governments and civil society should ignite de mand for quality in the population to empower people to hold systems accountable and actively seek high -quality care.

Midterm review of Health Sector Transformation Plan I (HSTP I): HSTP I has put Quality with Equity as one of the four transformational agendas. The Midterm review of HSTP-I found the lack of a standard set of Quality Improvement (QI) or Quality Assurance (QA) indicators. The review indicated that the Maternal and Newborn Health Quality of Care Network (MNH QoC Network) established using the Ethiopian Health Institute Alliance for Quality (EHIAQ) as a platform; Improving Nursing Services Initiative) have gained momentum. Other envisioned mechanisms (e.g., center for health equity), were not, however, established. The intervention of equity and quality are limited in scale (e.g., initiatives and promising practices) to bring significant influence on health outcomes. The functionality (e.g., health workforce (HW), infrastructure, commodities) and readiness of HFs (e.g., availability of electricity and water, sanitation and hygiene [WASH] amenities) continue to negatively affect other efforts being made to improve responsive and quality health services. With the focus on improving quality, there is increasing fragmentation of QA/QI (e.g., infrastructure, supply -chain efforts not fully aligned/coordinated) being pushed by different directorates to take their own interventions forward.

National Health Care Quality Strategy: The National Health Care Quality Strategy focused on improving quality across the spectrum of the healthcare system from prevention to palliative care, with special emphasis on the priority public health areas including MNCH, specifically reducing maternal and neonatal mortality and malnutrition, especially the prevention and management of Severe Acute

Malnutrition (SAM). A review of implementation of the NHSQ showed that many within MOH, RHB and facilities partners and professional associations are not fully aware of the content and in some cases not seeing the document or heard about it. The review also indicated that the strategy lacks clarity in priority interventions, proposed quality structures and responsibilities. Even though most of the interventions under each strategic focus area are initiated, few are completed. Most services are not responsive to the user’s needs; very little is done to activate patient and community demand for quality services and provision of patient centered care; and linkage with relevant health agencies including the

Health Insurance Agency is not yet happening. Efforts are observed to use data for improvement and decision making but overall practice needs more intervention to maximize the efforts and institutionalize in the system.

Health Sector Transformation Plan II (HSTP II) The HSTP II re-focuses quality by creating high-performing primary health care units, ensuring active engagement of the community in service delivery, and continually improving clinical care outcomes. It defines High-quality health care as health system that: ensures universal health coverage built on quality of care; standardizes and implements evidence-based interventions that demonstrate continual improvement; ensures that all people with chronic conditions are able to minimize the condition’s impact on the quality of their lives; fosters a culture, system, and practices that reduce harm to patients, seeks a benchmark against similar systems that are delivering best performance; emphasizes continuous learning and knowledge management for improvement; and engages communities.

Gender Analysis: The Gender Analysis done for the ECBH and HSS Projects in 2019 identified that poor quality services influence both men and women’s choice of health facility and utilization of health services. The analysis indicated that the quality of gender-responsive health services, such as maternal health, and GBV responses are poor; there is no clear approach stipulating how gender parity for health workers can be achieved. Also, despite the low doctor-to-population and nurse-to-population ratio, greater emphasis is placed on increasing the supply of health workers in general. Poor service quality has caused men and women to not seek care, or bypass services as the nearest health facility. Obstetric violence (physical abuse, neglect, non-consented care, non-dignified care, or non-confidential care) continues to be reported in Ethiopian health facilities. In another example, 46 percent of individuals who used inpatient services bypassed the nearest inpatient health facility to their homes to seek health care at another health facility. The analysis recommended considering supporting the public and private for profit as well as private non-profit health facilities in raising service quality standards. It also suggests the establishment of Quality Assurance standards for private -non-profit facilities. As stipulated in HSTP II the national Quality strategy will inculcate patient safety as its corner and this activity included interventions around ensuring these efforts.

Initial Environmental Analyses and Climate Risk Assessment: In accordance with USAID policies and procedures related to environmental compliance ADS- Chapter 204, USAID/Ethiopia Health

Office developed an umbrella IEE covering all activities, including the Primary Health Care Unit

(PHCU) now named as Primary Health Care QOC activity, under the Increased Utilization of Quality under the Health Services Development Objective (DO2). The DO2 IEE was amended to extend the validity of the IEE till 2024 HERE. The IEE gave a Negative Determination with condition threshold decision. Accordingly, the Implementing Partner (IP) developed an Environmental Mitigation and

Monitoring Plan (EMMP) and regularly reported on compliance status through a formal

Environmental Mitigations and Monitoring Report (EMMR). As the amended IEE expires before the end of this activity, the COR for this activity should work with the MEO to prepare an amendment to extend the validity of the IEE in early 2024. A climate risk analysis has been prepared for all activities under the ECBH project. The climate risk analysis established that climate risks were low for all project elements including the Quality-of-Care activity. Accordingly, no further climate risk management is required for the Quality-of-Care activity.

F. LME and CLA Considerations

The activity will support strengthening of evidence generation and utilization efforts of the health system to ensure better QOC in RMNCAH services using routine data systems as well as specific operation research. The activity will leverage the efforts of actors supporting the routine health information system to inculcate QOC data points and indicators to institutionalize evidence generation and utilization for

QOC in RMNCAH and accountability systems.

The activity should utilize a systematic process of collecting and analysis of performance data and other information such as qualitative insights, data collection on a more ad hoc basis, or more in -depth exploration into the achievement of results. The activity’s monitoring approach should demonstrate the

“what, how and when” the implementing partner measures and analyzes data to inform judgments about the outputs and outcomes of the intervention as a basis to improve effectiveness and/or inform decisions.

Monitoring will also include programmatic assumptions and the operational context of the activity in order to recognize trends and shifts in external factors that might affect the activity’s performance. It is also critical to demonstrate monitoring efforts that will be used to identify any gender gaps. The monitoring plan should also explain how the implementing partner plans to ensure data quality to fit-for-purpose. The recipient will develop a monitoring plan that includes performance indicators;

description of each indicator including baseline data; targets; and Performance Indicator Reference

Sheets (PIRS).

The recipient should also include a midterm or/and final performance evaluation plan; and a baseline status may be documented from secondary data sources or with additional primary data; and show if they intend to conduct an internal evaluation using its own staff or a contractor. USAID will conduct an independent evaluation on this activity. The plan should identify all evaluations that the partner will manage over the life of the activity and should include information on the type of evaluation

(performance or outcome/impact); purpose and expected use, possible evaluation questions, estimated budget, and expected level of USAID involvement, such as reviewing an evaluation statement of work

(SOW) or a draft report.

https://docs.google.com/document/d/1kUByn74pFNZdlztkDiqDUFRA3Yi3nnSXeQlY-ISjEUo/edit

G. Choice of Instrument

Based on preliminary consultation with the health office and the nature of the activity, the design team proposes Cooperative Agreement as the choice of instrument for this activity. The team will have co -creation opportunities including an RFI before the full solicitation is announced to get more input from the market. Additional co-creation efforts will be made during and after the award of the activity in consultation with AO.

H. Project Management Approach

The potential awardee will present a detailed human resource management plan to deliver the expected results under this activity. The key staff mix shall include chief of party, technical director, senior

Quality of Care expert, MEL director, and one other staff that the potential IP proposes to be a key staff member. The potential awardee will present a conflict sensitive approach and show experience in implementing interventions in conflict environments. The activity is going to be managed under the

ECBH project and an AOR will be assigned from the ECBH project team and alternate AOR from the

HSS project to ensure proper linkage between the two health project teams. The AOR will work with the Project lead to establish an activity oversight team that is composed of experts from Supply chain cluster, Information System cluster, Human Resources for Health team, Child health and Primary health

Cluster for better technical support and monitoring. The Activity will work with the SBCH andh, Empowered Communities under ECBH and HWIP and Digital Health Activity (DHA) under the HSS project for improved health system performance management, particularly at primary health care levels.

I. Estimated Cost

The Estimated…