ethiopia family planning...

Ethiopia Family Planning

Landscape

 FP situational landscape

 Partner landscape

 Plan activities & elements

Contents

2

Family Planning Situational Overview

CIA W

orld Factbook; Population R

eference Bureau – 2014 P

opulation Data S

heet

  Population:   95.9 million (13th largest in the world, 2nd largest in Africa)   43.5% of the population is Ethiopian Orthodox, 33.9% is Muslim,

and 18.6 % is Protestant.   Ethiopians are primarily rural, with only 19% of people living in

urban areas (Addis Ababa is the largest city, with 2.86 million people). The annual urbanization rate is 3.6%.

  Life expectancy at birth is 62 for males and 65 for females.   44% of the population is under 15 years of age.

  Economy and social development:   GDP per capita is ~$1300 (USD PPP)   39% of the population lives below the poverty line   Main economic sectors are industries, agriculture, and services

  Geography:   Landlocked country; imports most goods through Djibouti   9 Regions: Afar, Amhara, Benishangul-Gumuz, Gambela,

Harari, Oromia, Somali, Southern Nations, Nationalities and People’s Region (SNNP) and Tigray

  2 Administrative Cities: Addis Ababa and Dire Dawa   Healthcare System:

  3 tiers: Primary (Primary hospital, health centre, health post); Secondary (General hospital); and Tertiary (Specialized hospital)

Country Overview: General Development Indicators

4

Ethiopian Central Statistics Agency; Population Reference Bureau; 2014 United Nations Department of Economic and Social Affairs; World Bank

 Ethiopian Central Statistics Agency; Population Reference Bureau; United Nations Department of Economic and Social Affairs; World Bank

Current Country Context: Reproductive Health Indicators

Key health indicators

420

28

Maternal mortality

ratio

Under 5 mortality

rate

52 Infant

mortality rate

Reproductive health indicators

… are linked to demographic growth

4.1

2014 2024

2.1% ▪  Urban: 2.2 ▪  Rural: 4.5

Total fertility rate Population growth rate

Population projections, medium variant Population in millions of people

95.9 121.9 148.1 19.0 % urban 23.7 % urban 28.9 % urban

▪  Natural increase: 2.1%

▪  Net migration: -0.23

2034

5

HSTP, FP2020 Committments

  Increase CPR from 42% (in 2014) to 55% in 2020

  Reduce TFR from 4.1 (in 2014) to 3.0 in 2020

  Reach 6.2 million additional women & adolescent girls with FP services

The Government of Ethiopia has outlined the following objectives to advance FP

Overall Objectives:

Financial Commitments

Program & Service Delivery Commitments:   Ensure Family Planning Commodity Security

  Increase uptake of long-acting reversible methods

  Expand youth-friendly services, with a focus on adolescent girls

  Scale up delivery of services to hardest to reach groups

  Monitor availability of contraceptives

  Increase the budget allocation for FP annually

OBJECTIVE

6

UNFPA, In-depth analysis of EDHS 2000-2011; Central Statistics Agency, Ethiopia Mini Demographic and Health Survey, 2014

CPR in Ethiopia has risen dramatically in the past 14 years

0

5

10

15

20

25

30

2000 2005 2011 2014

Female Sterilization

IUD

Implanon

Injectables

Pill

Condom

Lactational Ammenorhea

Other Traditional

Rhythm Method

Withdrawal

OBJECTIVE

Contraceptive use trend between 2000-2014 in Ethiopia

Method mix Percent, CPR (married women)

7

Total population and modern contraceptive users between 2000-2020 in Ethiopia

EDHS, 2000, 2005, 2011, mDHS 2014, Spectrum population projection

Still, CPR must increase significantly to reach Ethiopia’s FP objective of 55% CPR by 2020

0

2

4

6

8

10

12

14

16

18

2000

20

01

2002

20

03

2004

20

05

2006

20

07

2008

20

09

2010

20

11

2012

20

13

2014

20

15

2016

20

17

2018

20

19

2020

CPR Total

OBJECTIVE

To reach the 55% objective, 3 million additional married women will need access to FP by 2020

Number of married women of reproductive age, total and users of modern contraceptives Million

8

UNFPA, DHS 2000 – 2011 In-Depth Analysis

  Limiting

  Spacing

Filling existing demand is critical, but will not reach the 2020 objectives alone

Demand creation, access to limiting and spacing will all be key parts of FP scale-up

28.6 16.3

9

53.9 55

0

10

20

30

40

50

60

2011 CPR Unmet Need Potential CPR 2020 Objective

DEMAND

2020 Objective Compared to 2011 CPR and Unmet Need

2011 CPR and Unmet Need Percent, women (married)

9

Central Statistics Agency, Ethiopia Mini Demographic and Health Survey, 2014

Knowledge of contraceptive methods: 96% of women know at least one method, but

significantly less know LARM

96.3

73.8

87.2 92.9

71.8

38.4 38.6

52.1

Any Method Condom Pill Injectables Implants IUD Sterilization Any traditional method

5

Short- Acting Methods Long-Acting Methods

DEMAND

Knowledge of contraceptive method, 2014

Knowledge of contraception, by method type Percent, women (married)

10


Majority of contraceptive users in Ethiopia use short-acting methods, with 77% of

modern method users relying on injectables

DEMAND

Contraceptive use in Ethiopia, 2014

Modern method mix Percent, CPR (married women)

40.4

31.0

2.6 0.3

5.0 1.1 0.1

IUD Female Sterilisa-

tion

Implants Male Condom

Pill Injectables Any modern method

84% of Ethiopian women using modern methods rely on short-acting methods

11

30.3

20.3 21.5 15.8

11.6 7.8

1.5

2.4

1.5 5.1

9.8 15.8 19.9

13.7

Central Statistics Agency, Ethiopia 2011 Demographic & Health Survey

Younger women want to space pregnancies, and older women want to limit

35-39 30-34 25-29 20-24 15-19 40-44 45-49

Unmet need to space Unmet need to limit

Unmet need amongst married women of reproductive age by age group, 2011 Percent, women (married)

7.8 0.9

12.2 8.1

30.4

7.9

22.0

6 or more 5 4 3 2 1 0 children

Ideal number of children1

Percent, women (married)

1 Does not sum to 100% due to non-numerical answers and rounding

DEMAND

12


Despite relatively high demand, health workers are unlikely to discuss FP with non-users

Adolescents are least likely to discuss FP

DEMAND

56.5 56.6 56.5 58.7 56.4 51.6 28.3

Demand for Family Planning, 2011 Percent, Women (married)

45 - 49 40 - 44 35 -39 30 - 34 25 - 29 20-24 15-19

11.4 17.8 21.8 20.3 27.3 25.3 19.0

45 - 49 40 - 44 35 -39 30 - 34 25 - 29 20-24 15-19

13

Percent, women (married, family planning non-users) Women who discuss FP either with a fieldworker or at a health facility in the past 12 months, 2011

•  There is lack of youth-friendly services and youths lack informed choice •  There is a growing number of youths who use emergency contraceptives as a

mechanism to prevent unplanned pregnancies rather than using consistent FP method


As women get older, demand for limiting grows, yet LARM use increases minimally

0

5

10

15

20

0

1

2

3

4

5

6

7

8 LARM Desire for Limiting

DEMAND

Change in LARM Use and Unmet Need for Limiting by age group, 2011

Total LARM CPR (primary axis) and Unmet Need for Limiting (secondary axis) Percent, women (married)

14

Myths and misconceptions around contraceptives likely contribute to low demand   Contraception (especially long acting methods) causes

infertility   Government is using family planning to reduce the size

of certain populations   IUD can cause side effects such as blindness, infection,

and cancer   IUD and Implants can migrate to other parts of the body

(e.g. brain)   IUD results in pregnancy   Long acting methods cannot be used by women who

have not yet had children   Contraception reduces sexual pleasure/libido

“Depo-Provera and pills are preferred to long acting methods among Somali population…this is because there is [misconception] that LARM cause infertility and irreversible sterility and are unacceptable choices of FP methods”

- RHB Staff, Somali Region

UNFPA, In-depth analysis of EDHS 2000-2011; Central Statistics Agency, Ethiopia Mini Demographic and Health Survey, 2014; Interviews with regional health bureaus

CPR varies significantly by region, but most saw growth over the last 14 years

0

10

20

30

40

50

60

70 2000 DHS 2005 DHS 2011 DHS 2014 MDHS

DEMAND

CPR Growth Trend between 2000-2014

CPR, by region Percent, women (married)

15

Regions have taken various FP approaches to increase demand   Addis Ababa took a three-layered

IEC/BCC approach to create demand   Several regions upgraded

infrastructure to provide privacy during counseling and service provision, improving quality

  Benshangul-Gumuz RHB worked with religious leaders to improve acceptability of FP within the community

  Dire-Dawa RHB expanded service provision at non-healthcare facilities, such as workplaces and schools to improve access

  Oromia RHB noted effective coordination among partners as key to smooth program implementation


FP use varies among religious groups Many religious leaders oppose use of Family Planning

Orthodox 47%

Protestant 22%

Catholic 1%

Muslim 28%

Traditional 1%

Other 1%

Religion in Ethiopia, 2011

Population Distribution, by Religion Percent, women (age 15-49)

18.5 15.8

12.0 11.9 7.6 5.8

3.6

2.9

3.9 1.7

1.2

0.9

1.0

1.1

0.7

3.7

0

5

10

15

20

25

Short Term Long Term Other

Contraceptive Use by Religion, 2011

Method Mix, by Religion Percent, women (age 15-49)

16

DEMAND


Unmet need varies by religion IEC/BCC should respond to the varying religious

background

4.8 3.9 4.8 3.9 6.2 7.1 7.3

Average Orthodox Protestant Catholic Muslim Traditional Other

Total Fertility Rate by Religion, 2011

Average number of children

25.8 23.3 26.3 28.4 31.0 35.3 30.5

Average Orthodox Protestant Catholic Muslim Traditional Other

Unmet Need by Religion, 2011


17

DEMAND


Women’s role in decision making around their own reproductive health is critical to

successfully increasing FP uptake

18

FP Trends based on Women’s Empowerment, 2011

16.3 24.6

33.7

5.6 5.0

4.7

0 2-3 3

28.5 27.5 23.2

# household decisions in which women participate

  In a male-dominated society, such as in the pastoralist regions, women have limited decision-making powers over contraceptive use

  Women travel long distances to get FP services; they have great interest in using FP services, but would like to keep it a secret

  The success of the three-layered BCC/IEC approach Addis Ababa City Administration shows how important it is to target individuals, families, facilities, and communities to increase FP uptake

CPR Percent, women (age 15-49)

Desired number of children women (age 15-49)

Unmet need Percent, women (age 15-49)

When women are empowered within their households and community:   FP uptake increases and unmet need

decreases   Desired number of children decreases

3rd level

2nd level

Primary Health Care Unit

(PHCU)

Health Sector Transformation Plan V (draft) Growth and Transformation Plan Annual Progress Report for FY 2012/13

Access has improved through PHCU, but LARM service delivery points are still lacking

19 Available in rural areas

SERVICE DELIVERY AND ACCESS

Steriliza-tion (f) IUDs

Injecta-bles Implants

Some HEWs are currently being trained to offer implanon insertion, however referral to the Health Centre is required for removal

Condoms (m) Pills

Steriliza-tion (m) Description

Health posts (HPs)

▪  Provides preventative services and promote health; limited curative and rehabilitative services

▪  Catchment pop: 3,000-5,000 (~5 HPs for one HC)

▪  32,252 HEWs deployed in rural areas and 4,084 in urban areas in 2012/13

Zonal Hospital

▪  Provides sub-specialized referral services

▪  Catchment pop: 1-1.5 million

Specialized Hospital

▪  Provides specialized health services ▪  Catchment pop: 3.5– 5 million

▪  Organizes community for learning and cooperative action

▪  Volunteers within 0.5-1km distance form one-to-five networks

▪  One village has one health development teams of about 25-30 households with 5-6 networks

Health Development

Army

District Hospital

▪  Provides most health services and able to support referrals from HCs

▪  Catchment pop: 250,000

Health Centers (HCs)

▪  Promotes health, prevents diseases, and provide basic curative services

▪  First referral points for HPs ▪  Catchment pop: 15,000-25,000

16,048

Number of facilities, 2013

~2,026,474

3,100

▪  2 Health Extension Workers

Typical staff/training

▪  Community-based volunteers

▪  Nurse ▪  Midwife ▪  Clinical officer ▪  General Medical

Officers

▪  Nurse ▪  Midwife ▪  Clinical officer

Methods offered, although not necessarily in stock or providers trained

▪  Nurse ▪  Midwife ▪  Clinical officer/

Medical Licentiate ▪  Specialized Doctors

(Obstetricians and Gynecologists)

1st level

Long-acting methods Short-acting methods

93.4% PHCU coverage in 2012/13

While most HEWs are female, In some regions, such as Afar, many of the HEWs are men, making it a barrier to FP service expansion, as women do not feel comfortable seeking information from men

1&2: Health and Health Indicators 2012; 3: MOH 2012 Health Facility List; 4: 2007 Census and 2011 National Statistics

HEW Program aims to increase access in rural areas, but their current distribution is not proportionate to population density

20

Pop density4, # per sq km

Health Facility3, # per mn pop

Nurse/ Midwife2, # per 10k pop

HEW1, # per 10k pop Region

1.0

3.0

3.7

3.9

3.9

4.1

4.4

4.6

4.6

6.1

8.9

SNNP

Affar

Oromia

Harari

Amhara

Tigray

Benishangul

Addis Ababa

Gambela

Somali

Dire Dawa 3.9

8.1

3.8

9.5

10.3

17.3

3.4

3.4

5.2

8.0

6.7

33.2

46.6

43.2

42.2

35.7

48.7

42.8

47.7

44.6

90.9

43.0

219

16

5

111

141

5,198

19

15

549

104

SERVICE DELIVERY & ACCESS

5,198

These sparsely populated regions need more HEWs


In Ethiopia, contraceptives are primarily distributed through the public sector

Male condom are an exception - most people acquire it from private pharmacies and shops

SERVICE DELIVERY & ACCESS

82.0 67.2

85.5 92.4

11.7

13.4 30.1

13.1 3.5

29.6

1.3 2.5 0.5 0.1

58.7

3.2 0.2 0.8 4.0

0 10 20 30 40 50 60 70 80 90

100

All Modern Methods

Pill Injectable Implant Male Condom

Public Private Other Missing

21

Source of Contraceptives, 2014

Source of modern contraceptives, by method Percent, women users of modern contraceptives (15-49)

Interview, PFSA, September 23, 2014; Growth and Transformation Plan Annual Performance Report

  PFSA is the primary agency to procure, store, and distribute FP commodities and consumables   Serves both public and private health facilities and generates revenue

through service charges   Operates 10 distribution hubs nationwide, and expected to add 6 more

between 2014-2015   National Growth and Transformation Plan priority:

  Increase the availability of pharmaceuticals (medical equipment and products)

  Distribute essential drugs at an affordable price   Ensure adequate supply to health facilities   Improve rational drug use   Implement drug control and abuse prevention strategy

  Procurement lead time has reduced from 240 days from 2010/11 to 140 days in 2012/13

Improvement of supplies and equipment procurement is a national priority

PROCUREMENT AND SUPPLY CHAIN

22

JSI DELIVER Project Contraceptive Security Indicators Dashboard; JSI DELIVER Project, Health Logistics Quarterly, Ethiopia Vol 6. No 2.

  All FP commodities were in-stock at the central level throughout FY2014   Less than 5% of the public health facilities had stock-outs of FP commodities

  Majority of the stock-outs were seen in emerging regions

  Health commodity management information system is being rolled out   However, currently, distribution does not seem to align with need, effecting method choice   In some districts, facilities rely on implementing partners to fill gaps in commodity supply   Supply chain management system must be further strengthened

Stock-outs are less common, but they are still a challenge in the emerging regions

Availability of FP commodities in health facilities % of health facilities with commodity out of stock at time of Visit, April 2013 – March 2014

0.3 1.4 0.9 1.3

2.6

0.6 1.4 1.4

0.6

3.5

0.3

6.4

0.5 0.3

5.1

0.5

7.6

2.1 1.1

2.6

Injectables Pills Condoms Implants IUCD

Apr-Jun

Jul-Sep

Oct-Dec

Jan-Mar

PROCUREMENT AND SUPPLY CHAIN

23

FP is seen as a key policy objective, with FP targets included in many health and

national strategies and plans

POLICY AND ENVIRONMENT

“High fertility ranks second only to HIV/AIDS as the greatest perceived threat to individual and social well-being” Three broad strategies of FP: •  Create acceptance and demand for FP, with special emphasis on populations rendered vulnerable by

geographic dispersion, gender, and wealth •  Increase access and utilization of quality FP services, particularly for married and unmarried young

people and those who have reached desired family size •  Delegate to the lowest service delivery level possible, the provision of all FP methods, especially long-

term and permanent methods, without compromising safety or quality of care

The National Reproductive Health Strategy, 2006-2015, is the guiding policy for FP

•  Maternal and neonatal health one of the six strategic health areas of focus to improve equitable utilization with set targets for 2020 for CPR and TFR

The Health Sector Transformation Plan V (Draft)

•  Increasing family planning services (CPR) is one of eight targets set for health •  Highlights population and development as a key cross-cutting issue; notes that effective family planning

program is essential to improve all citizen’s living conditions while managing the capacity to develop and use natural resources

The Growth and Transformation Plan

24

Commitments made at July 2012 London Summit on Family Planning

At the London Summit on Family Planning, Ethiopia made significant commitments to

expand access to FP


  Increase CPR from 29% (in 2011) to 69% in 2015   Reduce TFR from 4.8 (in 2011) to 4 in 2015   Reach 6.2 million additional women & adolescent girls with FP services

Overall Objectives:

Financial Commitments

Program & Service Delivery Commitments:   Ensure Family Planning Commodity Security   Increase uptake of long-acting reversible methods   Expand youth-friendly services, with a focus on adolescent girls   Scale up delivery of services to hardest to reach groups   Monitor availability of contraceptives

  Increase the budget allocation for FP annually

25

  Demand: Should FP guidance/policies be developed specifically for married adolescents, unmarried women and youth to facilitate demand creation?

  Access: How can long acting and permanent methods be prioritized while maintaining equitable access to all methods?

  Supply chain: Procurement and Supply Chain by Private Health Sectors to Public Health Facilities

  Health finance: Should insurance and/or out-of-pocket payment play a role in financing FP programs with a view for sustainability?

  Coordination: How can coordination with the private sector support the governance and leadership of the FMOH in FP programs?

Yet, details that have programmatic effect have not been clarified

26


Ethiopia Federal Ministry of Health. April 2014. Ethiopia’s Fifth National Health Accounts 2010/2011

Health expenditure has increased, but yet to meet national target

FINANCING

Total Health Expenditure by Funding Source (million Birr)

Gov’t

Donor HH

Other 2% 31% 37% 31% 22%

39%

37%

1%

1%

16%

50%

34%

4.5

11.1

26.5

2004/05 2007/08 2011/12

  Total health expenditure doubled between 2007/08 and 2011/12 primarily through donor support

  However, the government’s share of total health expenditure has decreased   More than half of the government contribution to health care is

from regional and local governments

  Total health expenditure amounts to 5.4% of GDP, surpassing WHO recommendation of 5%

  However, total government expenditure on health of Birr 4.1 billion is still only 5.6% of total government budget

  HSDP-IV Health Finance Targets   Increase per capita expenditure on health from US$16.1 to US

$32.2   Increase government expenditure on health budget as a

proportion of total budget from 5.6% to 15%   Increase proportion of public health facilities retaining and

using their revenue from 20% to 100%   Increase proportion of people enrolled in health insurance from

1% to 50%   Increase health budget utilization rate to 90%

27

Ethiopia Federal Ministry of Health. April 2014. Ethiopia’s Fifth National Health Accounts 2010/2011

FP is heavily reliant on donor and out-of-pocket funding, and majority of funds is

used by the public sector

FINANCING

Total RH Health Expenditure: Birr 3.5 billion RH spending, which includes FP services, has remained static at 13% of Total Health Expenditure since 2007

Public

Rest of the World

Household

Private (non-HH)

Source of RH Funds

28%

3%

47%

21% Fed Gov’t

OOP

Management Agent of RH Funds

16%

3%

18%

31%

Rest of the World

NGO

3%

28%

Private

Non-Fed. Gov’t

Public Facilities

Other

User of RH Funds

15%

16%

12%

38%

Public Health

19%

Gov’t Admin

Private Facilities

28

Interview, PFSA, September 23, 2014; JSI DELIVER Project Contraceptive Security Indicators Dashboard; RHInterchange

  Although basket fund procurement mechanism was established in 2006/07, various donors procure FP commodities through various mechanisms   Global Fund procures commodity through PFSA, while UNFPA and social franchises procure by

themselves   FP procurement has been volatile, but government financing has grown in recent years   Distribution of drugs and medical equipment supplies to public health facilities:

  2010/11: Birr 3.5 billion   2012/13: Birr 6.77 billion

Government ownership of FP procurement has increased, but fragmentation still exist

Contraceptive financing by

source Millions USD

12.8 20.9

9.5 16.6 21.4

13.5 (42%)

6.0

6.0

2.8 9.7

11.4 4.8 6.8 (21%)

3.0

3.5

3.6 9.3

29.2

8.5 9.5 (30%)

6.1

0.2

2.1 (6%)

2008 09 10 11 12 13 Average

Other

UNFPA

USAID

Government

21.8

36.5

16.1 19.0

57.1

34.8 32.0

29

FINANCING

Interviews with regions

  Addis Ababa secured an ear-marked budget for FP programs in 2012   Budget to grow to Birr 3.3 million in 2015   Budget supports commodities and training

  SNNPR also has a direct FP budget   [hopefully get more details through

Mekonnen’s notes]   Amhara also allocates a budget for FP

programs as part of the General Financing System for Reproductive Health Programs   Budget used primarily for commodity

procurement

Regional resource mobilization for FP is critical to program sustainability

Most regions do not yet have a line item for FP

FINANCING

30

  However, most regions still do not have their own ear-marked budget for FP programs   Regional officials have many competing

priorities with FP programs & topic is controversial that prioritization of FP through budget line item is challenging

  For regions with budgets, it is still insufficient, and budget line items for consumables must also be added to ensure consistent and high quality FP service delivery

Some successes… But many more challenges…

Regional Landscape Interviews, January 2015; Growth and Transformation Plan Annual Performance Report

HMIS available nationwide, but consistent data reporting is lacking, and data is not

always used in making decisions

  HMIS indicators have been recently revised at the Federal level

  At the regional level, data collection and use is frequently inadequate

  There is low capacity for data analysis and use in decision making at the regional and woreda levels   For example, Contraceptive Acceptance

Rate coverage was slow to increase in the first 3 years of the GTP, partly due to the information not appropriately recorded and reported through the HMIS

31

MONITORING, DATA, AND COORDINATION

69

87

75

97

Hospital Health Center

2012/13 2010/11

HMIS Performance at Facilities

Percent, Public Facilities with HMIS

 Coordination between relevant ministries at Federal level is poor

 Coordination between IPs, donors etc at federal level is also poor

 Coordination at regional level between government sectors and the various actors including IPs is poor, regions don’t have a well functioning TWGs

 Lack of adequate technical support from the MoH to the regional health bureaus

 No FP focal person at regional health bureaus which is creating a challenge to facilitate FP activities including coordination at regional level

Federal and regional coordination

32

2005 and 2011 DHS; Growth and Transformation Plan

  Private sector now provide approximately one third of all health service provision

  NGOs and the national social marketing program have generated a quarter of total CYP

  GTP highlights the potential contribution of the sector in pharmaceutical production and service provision

  Yet, does not further delineate the specific role and services it should target or market segment that the private sector can be serving

Private sector is growing and actively providing services; key policies value the sector, but their role is yet to be defined

MONITORING, DATA, AND COORDINATION

27.0

10.6

20.3

30.2

13.1

3.5

29.6

Pill Injectables Implants Male Condom

2005 2011

33

FP obtained through private facilities, by method


Partner Landscape

We interviewed 30+ organizations Organizations Names

Government

MOH Berhane Assefa

PFSA Yemaneberhan Tadesse

Pop. & Dev. Directorate Alula Sebhatu; Fikre Gesso

Organizations Names

NGOs

Abt Associates/ PHSP Tesfai Gabre-Kidan; Asfawossen

Addis Ababa U./ PMA2020 Assefa Seme; Solomon Shiferaw

CARE Sister Alemshet Mekonnen

DKT Dagnachew Alemayehu; Abdu Ebrahim; Dagmawit Girmay

DSW Marta; Tirsit Girshaw

EngenderHealth Jemal Kassaw

FHI 360/ PROGRESS Admassu ; Banchiamlak, Abner, Btelhem

Ipas Demeke Desta

Jhpiego Hannah Gibson; Alemnesh; Tigist

JSI/ DELIVER Paul Dowling; Woinshet Nigatu

JSI/ L10K Nebreed Fesseha; Meheret; Wuleta

Merck/MSD Tewodros Alemseged

MSI

Getachaw (Acting Director of Ops); Getachaw (Financial Analyst); Nils Gade

Pathfinder International Kidest Lulu

World Vision Etsub Brhanesilassie

Donors

Gates Foundation Monica Kerrigan; Clea Finkle

Packard Foundation Yemeserach Belayneh

UNFPA Muna Abdullah; Sufyan Abdulber; Beyeberu Assefa

USAID Elizabeth Haytmanek; Zewditu Kebede

WHO Luwam Teshome

CSOs

CORHA Dejene

Ethiopian Medical Assoc. Abiy; Yeneneh

Ethiopian Midwives Assoc. Mulatu Ayele; Meaza Semaw

Ethiopian Nurses Assoc. Asfaw Haileselassie

Ethiopian Public Health Assoc. Tesfa Demelew Taye

Ethiopian Soc. Ob/Gyn Dereje Negussie

Family Guidance Assoc. Ethiopia Genet; Desta; Haregewoin

Population, Health and Environment Consortium, Ethiopia (PHE)

Negash Teklu, Alem Mekonnen; Ahmed Mohammed

35

8 Major Priority Areas were Identified through Interviews

Demand Creation

Human Resources for Health

Service Delivery & Access

Procurement & Supply Chain

Leadership, Management & Coordination

Public-Private Partnerships

Financing

Data Demand and Information Use

36

# in parenthesis denote the number of organizations that identified this issue as important to be addressed

  Behavior change communication (8): Myths and misconceptions held by users, community, and providers must be addressed; need for robust and tailored communication strategy and intervention to improve acceptability

  LARM and permanent methods (7): Increase awareness and demand for these specific FP methods

  General demand creation (6): Many know of FP, but not necessarily the various forms of FP

  Empowerment of women (6): Awareness building around women to have their say in choice

  Community sensitization (5): Incl. outreach to religious and traditional leaders

  Youth (5): Need targeted efforts for youths in and out of school, at universities, and for adolescent married girls

  Male involvement (4): Engage men in conversation around FP, gender, sexual and reproductive health

Demand Creation: Key Issues

37


  Training and capacity building (11): Need for further increased pre- and in-service training, building in long-term and permanent methods into the training curriculums, and staffing each facility level with appropriately trained staff

  Staff turnover (6): Need to understand why there is turnover and appropriately hire and assign staff to their positions

Human Resources for Health: Key Issues

38


  Rural/pastoralist access (11): Lack of services available/ lack of project resources targeted towards less populated areas; access inequity in hard to reach areas

  Method Mix (11): Full spectrum of method mix not available, due to causes such as lack of adequately trained staff and commodities; option for men (vasectomy) non-existent

  Youth friendly services (9): Need more youth-friendly facilities and services; missed opportunities for integration with life-skills building projects, youth centers, and universities

  Quality (9): Low quality of service in areas such as counseling (limits informed choice) and privacy

  Access to LARM and permanent methods (9): Limited accessibility specifically to long-term and permanent methods including removals of implants, due to causes such as lack of adequately trained staff and commodities

  Referral system (2): Inadequate referral systems to higher-level health facilities to access full spectrum of FP services (esp. for removals, LARMS, and permanent methods)

  Integration of FP with other MNCH services: Lack of integration with other MNCH services such as postpartum and post abortion contraception, as well as integration of FP with PMTCT and immunization

Service Delivery & Access: Key Issues

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  Distribution to health posts and HEWs (7): Geographical barriers and limited distribution mechanisms (e.g. only periodic drop-offs, rather than on demand) makes distribution challenging

  Procurement (4): Need for streamlined procurement system and train staff so that facilities orders ahead of time to prevent stock-outs

  Logistics Capacity (3): Not enough trained staff that can appropriately forecast use and procure at the facility level; lack of data and management capacity at the regional and national level to appropriately manage logistics

Procurement & Supply Chain: Key Issues

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  Central-level coordination (8): Need for coordination within the government across various ministries (e.g. engagement of youth around FP with Ministry of Youth), and between government, donors, and partners (e.g. scheduled TWG meetings)

  Coordination between government levels (6): While national-level FP commitment is strong, there is need for local-level ownership on FP initiative; need to build awareness around FP initiatives, need to focus building capacity of the leadership at all levels

  Regional coordination (5): Similar to national FP TWG, platform for regional coordination for the government and partners to reduce duplication and eliminate gaps

Leadership, Management & Coordination: Key Issues

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  Integration with national FP objectives (5): Private sector’s role in FP service provision unclear; segmenting the market and identifying where there could be a role for paid (subsidized) services

  Enabling environment (3): Need for overarching strategy and direction to be established by the government on how to engage the private sector; more efforts needed for capacity building of private facilities, as well as monitoring and supervising private facilities

  Improving accessibility (3): Unclear guidelines on what FP services could be provided through the private sector at each facility level

Public-Private Partnerships: Key Issues

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  General Financing (9): Need to secure financing options for the long-term for the entire program, including more engagement and funding supported by the government for trainings and consumables necessary for FP service provision; consider covering FP service under the national health insurance scheme

  Reproductive Health Commodity Security (8): Clear strategy to increase government funding towards RH commodity and supply and wean off of donor funding is necessary

  Government line items for FP (7): Currently almost entirely donor dependent, and government should take ownership; limited number of regions have also delineated FP budget lines

Financing: Key Issues

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  Monitoring capacity and data availability (4): HMIS is not fully functional at the facilities – information gaps are prevalent and interpretation of indicators vary from facility to facility; commodity availability data is only available at central-level, and facility-level data needs to be fed up to the central-level for better coordination and logistics management

  Information on users (2): Lack of data around FP user’s reasons for selected method, reasons for discontinuation, etc.; need to invest more to understand target group (e.g. youth)

  Research for program evidence building (2): Need to generate evidence around program effectiveness and identify most cost-effective programs

Data Demand and Information Use: Key Issues

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Thank You!

The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). It is implemented by Futures Group, in collaboration with Plan International USA, Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA).

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