EthiopiaService Provision

Assessment Plus-Census2014

Ethiopian Public Health Institute (EPHI)

Federal Ministry of Health

ICF International

Ethiopia

Service ProvisionAssessment Plus-Census 2014

Final Report

Ethiopian Public Health InstituteAddis Ababa, Ethiopia

Federal Ministry of HealthAddis Ababa, Ethiopia

ICF InternationalRockville, Maryland USA

October, 2014

This report presents findings of the 2014 Ethiopia Service Provision Assessment Plus-Census, which wasimplemented by the Ethiopian Public Health Institute in collaboration with the Ethiopian Ministry of Health. ICFInternational provided technical assistance. The 2014 ESPA Plus-Census is part of the worldwide MEASURE DHSproject which assists countries in the collection of data to monitor and evaluate population, health, and nutritionprogrammes. The survey was funded by the United States Agency for International Development (USAID), WorldBank, Irish Aid, WHO and UNICEF.

Additional information about the 2014 ESPA Plus-Census may be obtained from the Ethiopian Public HealthInstitute (EPHI), Gulele Arbegnoch Street, Gulele Sub City, Addis Ababa, Ethiopia. Telephone:+251.11.275.4647;Fax: +251.11.275.4744; website: http://www.ephi.gov.et

Information about the MEASURE DHS project can be obtained from ICF International, 530 Gaither Road, Suite500, Rockville, MD 20850 USA. Telephone: 301.572.0200; Fax: 301.572.0999; E-mail:reports@DHSprogram.com; website: http://www.DHSprogram.com.

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CONTENTSTABLES AND FIGURES ........................................................................................................................... iv

FORWARD................................................................................................................................................... v

ACKNOWLEDGEMENTS.........................................................................................................................vi

ACRONYMS AND ABBREVIATIONS ...................................................................................................vii

Executive summary....................................................................................................................................viii

1. Overview of the health system in Ethiopia ......................................................................................... 44

1.1 General description of the country ....................................................................................... 441.2 Key health indicators and trends .......................................................................................... 441.3 Major health policy and initiatives....................................................................................... 441.4 The health care system ......................................................................................................... 45

2. ESPA Plus-Census Methodology........................................................................................................ 48

2.1 Overview .............................................................................................................................. 482.2 Institutional framework of the 2014 ESPA Plus-Census ..................................................... 482.3 Objectives of the ESPA Plus-Census ................................................................................... 482.4. ESPA Plus-Census content and methods for data collection .............................................. 492.5 ESPA plus-Census Implementation ..................................................................................... 492.6 Facilities assessed by the ESPA Plus-Census ......................................................................51

3. Facility-level infrastructure and resources .......................................................................................... 55

Background ................................................................................................................................ 553.1 Availability of Specific Services.......................................................................................... 553.2 Basic Amenities for Client Services..................................................................................... 563.3 Availability of basic equipment ........................................................................................... 573.4 Systems for infection control ............................................................................................... 583.4.3 Waste management ........................................................................................................... 623.5 Laboratory Diagnostic Capacity........................................................................................... 643.6 Management systems to support and maintain quality services........................................... 663.8 Routine user fees or charges for different services .............................................................. 71

References................................................................................................................................................... 71

CENSUS PERSONNEL Appendix A............................................................ 73

MASTER HEALTH FACILITY LIST Appendix B........................................................................ 45

MAP (DISTRIBUTION OF FACILITIES) Appendix C ............................................................... 586

CENSUS INSTRUMENT Appendix D ....................................................................................... 641

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TABLES AND FIGURES

Table 2.1 Distribution of facilities, by region................................................................................ 52Table 2.2 Result of visited facilities, by background characteristics ............................................. 53Table 2.3 Distribution of facilities, by background characteristics ............................................... 54Table 3.1 Availability of specific services..................................................................................... 55Table 3.2 Availability of basic amenities....................................................................................... 56Table 3.3 Availability of basic equipment in the general outpatient service area ......................... 58Table 3.4 Capacity for processing of equipment for reuse ............................................................ 59Table 3.5.1 Standard precautions for infection control..................................................................60Table 3.5.2 Standard precautions for infection control..................................................................61Table 3.6 Waste management ........................................................................................................ 62Table 3.7.1 Laboratory diagnostic capacity, by facility type ......................................................... 65Table 3.7.2 Laboratory diagnostic capacity, by region..................................................................66Table 3.8 Client opinion, quality assurance, and HMIS ................................................................ 68Table 3.9 External supervision practices at the facility level......................................................... 69Table 3.10 Staffing pattern of facilities ....................................................................................... 70Table 3.11 User fee or charge for different services....................................................................71

Figure 2.1 Number of Primary, General, and Referral Hospitals. ................................................. 52Figure 2.2 Number of Health centers, by their operational status ................................................. 53Figure 3.1 Waste disposal method for infectious waste.................................................................64Figure 3.2 Waste disposal methods for sharp waste ......................................................................64

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FORWARD

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ACKNOWLEDGEMENTS

The following persons contributed to the preparation of this report:

Mr. Theodros Getachew, Ethiopian Public Health InstituteMr. Atkure Defar, Ethiopian Public Health InstituteMr. Mekonnen Tadesse, Ethiopian Public Health InstituteMr. Kassahun Amenu, Ethiopian Public Health InstituteMr. Habtamu Teklie, Ethiopian Public Health InstituteMr. Yoseph G/Yohannes, Ethiopian Public Health InstituteMr. Solomon Abay, Federal Ministry of HealthMr. Lewi Tibebe, Social Health InsuranceMr. Asfaw Kelbessa, Federal Ministry of HealthMr. Ibrahim Kedir, Ethiopian Public Health InstituteMs. Tigist Shumet, Ethiopian Public Health InstituteMs. Eden Getachew, Ethiopian Public Health InstituteDr. Belete Tafesse, Ethiopian Public Health InstituteMr. Terefe Gelibo, Ethiopian Public Health InstituteMr. Abebe Bekele, Ethiopian Public Health Institute

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ACRONYMS AND ABBREVIATIONS

AIDS Acquired Immune Deficiency SyndromeANC Antenatal CareARM Annual Review MeetingART Antiretroviral TherapyARV AntiretroviralBPR Business Planning ReengineeringCBHI Community-Based Health InsuranceCAFE Computer Assisted Field EditingDACA Drug Administration and Control Agencye-HMIS Electronic Health Management Information SystemCAPI Computer Assisted Personal InterviewingELISA Enzyme-Linked Immuno-Sorbent AssayEPHI Ethiopian Public Health InstituteESPA+ Ethiopia service provision assessment plusHEP Health Extension ProgramHEW Health Extension WorkerHIV Human Immunodeficiency VirusHMIS Health Management Information SystemIMCI Integrated Management of Childhood IllnessesITN Insecticide-Treated NetJCCC Joint Core Coordinating CommitteeJFA Joint Financing ArrangementJRM Joint Review MeetingMCH Maternal and Child HealthMDG Millennium Development GoalMLHPs Mid-Level Health ProfessionalsMOH Ministry of HealthNGO Nongovernmental OrganisationNHA National Health AccountPFSA Pharmaceutical Fund and Supply AgencyPHCU Primary Health Care UnitPMTCT Prevention of Mother-To-Child Transmission (of HIV)QA Quality AssuranceRHBs Regional Health BureausRDT Rapid Diagnostic TestSHI Social Health InsuranceSDI Service Delivery IndicatorSARA Service Availability and Readiness AssessmentSTI Sexually Transmitted InfectionUSAID United States Agency for International DevelopmentWHO World Health Organization

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Executive summary

The major health problems of the country remain largely preventable communicable diseases, reproductivehealth related problems and nutritional disorders. Despite major progresses have been made to improve the healthstatus of the population in the last two decades, Ethiopia’s population still face a high rate of morbidity and mortalityand the health status remains relatively poor.

There are multiple components that will influence this: available infrastructure; staff deployment and presence;and availability and quality of services provided. Although routine reporting will contribute to this understanding, at thisstage of the implementation of routine reporting, national surveys are required to further complement the availableroutine reporting.

The 2014 Ethiopia Service Provision Assessment Plus-Census was undertaken by the Ethiopian Public HealthInstitute (EPHI). Technical support was provided by ICF International under the MEASURE DHS Project. The United StatesAgency for International Development (USAID), World Bank, UNICEF, Irish Aid and WHO provided the financial support.

The objectives of the 2014 ESPA Plus-Census were to provide master facility list existing in the current year thatare managed by government, and assess basic resource and support system of health facilities

The 2014 ESPA Plus-Census assessed 3,820 facilities, except two health centers from Somali and SNNP regions dueto security problem. In addition, to complete the master health facility list of all governmental facilities, the ESPA+ Plus-Census questionnaire was able to capture the list of 15, 526 satellite health posts which makes a total of 19,346governmental facilities.

Emergency services are available in all hospitals and health centers (100 percent). Among all hospitals andhealth centers, other services most available are antenatal care and normal delivery services (each 99 percent), diagnosisor treatment of STIs excluding HIV (97 percent), and minor surgical services (96 percent respectively). Diagnosis, treatmentprescription or follow-up for TB, and inpatient services are the least likely available services among all health facilities (59and 52 percent respectively).

In general, a little under half (47 percent) of all facilities have regular, uninterrupted electricity (i.e., the facility isconnected to a central power grid, or has solar power or both, and power is routinely available during regular servicehours), or has a functioning generator with fuel.

In general, two-third of all facilities have an improved water source in the facility (i.e., water is piped into thefacility or onto facility grounds, or else water is from a public tap or standpipe, a tube well or borehole, a protected dugwell, or protected spring, or rain water, or bottle water), and the outlet from this source is within 500 metres of the facility.

On average, more than eight of every ten facilities (81percent) have a functioning client latrine (i.e., the facilityhad a functioning flush or pour-flush toilet, a ventilated improved latrine, pit latrine with slab), or else the facility hascomposting toilet.

Only 4 percent of all facilities have computer with internet (i.e., the facility had a functioning computer with accessto the internet that is not interrupted for more than two hours at a time during normal working hours), or else facility hasaccess to internet via a cellular phone inside the facility which is supported by the facility.

Overall, transport for emergencies is available in 84 percent of all facilities (i.e., the facility has a functioningambulance or other vehicle for emergency transport that is stationed at the facility and had fuel available on the day ofthe survey), or else the facility has access to an ambulance or other vehicle stationed at or operating from another facility.

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Among all government hospitals and health centers, 42 minutes is the average travel time from the health facilityto the ambulance station on different road types by different mode of transport.

Nine of every ten facilities have functioning equipment (including the necessary chemicals for HLD) for theprocessing method used.

Overall, only 20 percent of all health facilities have regular QA activities with observed documentation.

Among all facilities, only one-third of health facilities report having e-HMIS.

More than six of every ten facilities have an adequate system for disposal of sharps waste and infectious waste.

1. Overview of the health system in Ethiopia

1.1 General description of the country

Ethiopia is the tenth largest country in Africa, covering 1,104,300 square kilometers (with 1 million sq km landarea and 104,300 sq km water) and is the major constituent of the landmass known as the Horn of Africa. It is a countrywith great geographical diversity and its topography shows a variety of contrasts ranging from high peaks of 4,550 mabove sea level to a low depression of 110 m below sea level. It is bordered on the north-northeast by Eritrea, on the eastby Djibouti and Somalia, on the south by Kenya, and on the west-southwest by Sudan. Its geographical coordinates arebetween 8 00 N and 38 00 E.

Projections from the 2007 population and housing census estimate the total population for the year 2012 to be84.3 million. The country is among the least urbanized country in the world with 83.6% living in rural areas. The pyramidalage structure reflects the large number of children under age 15. Children under age of 15 account for nearly half (47 %)of the total population, a feature of populations with high fertility levels, while only about 4 % of Ethiopians are over age65. This population distribution is similar to that observed in the 2000 and 2005 surveys (EDHS, 2011).

Ethiopia is a Federal Democratic Republic government under the 1994 constitution. It is composed of nineRegional States and two City Administrations. The regional states and city administrations are subdivided into 817administrative Woredas (districts). A Woreda/District is the basic decentralized administrative unit and has anadministrative council composed of elected members. The 817 Woredas are further divided into about 16,253 Kebeles,the smallest administrative unit in the governance.

The decentralization of power to regional governments and local communities (woredas) is the principal deviationin governance between the current government and the previous ones. It begun with the ratification of the constitutionand has been continuously strengthened since then. The decentralization allowed regions and woredas to plan, implementand monitor all socioeconomic activities in their respective administrative levels. The role of Federal Governments andFederal Ministries has been limited to providing support in terms of budgets, policy formulations and capacity building.This approach is believed to have improved access to services and strengthen community participation and ownership ata grass-roots level.

1.2 Key health indicators and trends

The major health problems of the country remain largely preventable communicable diseases, reproductivehealth related problems and nutritional disorders. Despite major progresses have been made to improve the healthstatus of the population in the last two decades, Ethiopia’s population still face a high rate of morbidity and mortalityand the health status remains relatively poor. Figures on vital health indicators from EDHS 2011 show a life expectancyof 54 years (53.4 years for male and 55.4 for female), and an IMR of 59/1000 (DHS, 2011).

There are multiple components that will influence this: available infrastructure; staff deployment and presence;and availability and quality of services provided. Although routine reporting will contribute to this understanding, at thisstage of the implementation of routine reporting, national surveys are required to further complement the availableroutine reporting.

1.3 Major health policy and initiatives

Ethiopia had no health policy until the early 1960s, when a health policy initiated by the World Health Organization(WHO) was adopted. In the mid-1970s, during the Derg regime, a health policy was formulated with emphasis on disease

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prevention and control. This policy gave priority to rural areas and advocated community involvement (TGE, 1993). Thecurrent health policy, promulgated by the Transitional Government, takes into account broader issues such as populationdynamics, food availability, acceptable living conditions, and other essentials of better health (TGE, 1993).

To realize the objectives of the health policy, the government established the Health Sector DevelopmentProgramme (HSDP), which is a 20-year health development strategy implemented through a series of four consecutive 5-year investment programmes (MOH, 2010). The first phase (HSDP I) was initiated in 1996/97. The core elements of theHSDP include: democratisation and decentralisation of the health care system; development of the preventive andcurative components of health care; ensuring accessibility of health care for all segments of the population; and,promotion of private sector and NGO participation in the health sector.

Ethiopia’s Growth and Transformation Plan (GTP) 2011-2015 has been designed to maintain the rapid and broad-based economic growth enjoyed by Ethiopia in the recent past and eventually to end poverty (MOFED, 2010). The HealthSector Development Program (HSDP) is a key component of the GTP and its primary objective is to improve the health ofthe population through the promotion of preventive, curative and rehabilitative health services by:

• Improving access to affordable health services; and• Improving the quality of health services

The health policy in Ethiopia also takes into account broader issues such as population dynamics, food availability,acceptable living conditions, and other essentials of better health. The HSDP prioritizes maternal and newborn care, andchild health, and aims to halt and reverse the spread of major communicable diseases such as HIV/AIDS, TB, and malaria.The Health Extension Programme (HEP) serves as the primary vehicle for the prevention, health promotion, behaviouralchange communication, and basic curative care. The HEP is an innovative health service delivery programme that aims atuniversal coverage of primary health care. The programme is based on expanding physical health infrastructure anddeveloping Health Extension Workers (HEWs) who provide basic preventive and curative health services in the ruralcommunity.

The first phase of the HSDP (HSDP I) was initiated in 1996/97. Thus far, the country has implemented the HSDP inthree cycles and is in its fourth phase, HSDP IV (2010/11-2014/15). Assessment of HSDP III shows remarkableachievements in the expansion and construction of health facilities, and improvement in the quality of health serviceprovision.

HSDP IV is designed to provide massive training of health workers to improve the provision of quality healthservices and the development of a community health insurance strategy for the country (MOH, 2010). In addition, HSDPIV prioritizes maternal and newborn care, and child health. In line with the government’s current five-year national plan,the health sector continues to emphasize primary health care and preventive services; with focus on extending servicesto those who have not yet been reached and on improving the effectiveness of services, especially addressing difficultiesin staffing and the flow of drugs.

1.4 The health care system

The recently implemented Business Process Reengineering (BPR) of the health sector has introduced a three-tierhealth care delivery system: level one is a Woreda/District health system comprised of a primary hospital (to cover 60,000-100,000 people), health centres (1/15,000-25,000 population) and their satellite Health Posts (1/3,000-5,000 population)connected to each other by a referral system. The primary hospital, health centre and health posts form a Primary HealthCare Unit (PHCU). Level two is a General Hospital covering a population of 1-1.5 million people; and level three is aSpecialised Hospital covering a population of 3.5-5 million people. (HSDP IV, 2010).

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The devolution of power to regional governments has resulted in largely shifting the decision making for publicservice delivery from the centre to being under the authority of the regions and down to the district level. Offices atdifferent levels from the Federal Ministry of Health to Regional Health Bureaus (RHBs) and Woreda Health Offices sharein decision making processes, powers, duties and responsibilities. The Ministry and the RHBs focus more on policy mattersand technical support while Woreda Health Offices manage and coordinate the operation of the district health systemunder their jurisdiction.

Rapid expansion of the private for profit and NGO sectors is augmenting the public | private | NGO partnershipfor health and boosting health service coverage and utilization (HSDP IV, 2010).

The government has taken a wide range of measures to improve the health status of the population. A number ofhealth sector policies and programs have been developed and aggressively implemented. National health policy wasadopted in the early 1990s (MOH, 1993) and strategies such as nutrition strategy, child survival strategy and infant andyoung child feeding strategies were endorsed subsequently. A number of innovative programs and interventions havebeen developed and implemented to translate the policies and strategies in to action. The health sector developmentprograms and the health extension programs can be considered as the centerpieces in this accord. Changes in health caregovernance and health system management have been introduced. Decentralization in health care governance andmanagement has been adopted. Relentless efforts have been made in expanding health facilities, human resourcedevelopment and health care financing.

Health sector reform - health reforms have intensified through the application of Business Process Reengineering(BPR), leading to a set of new approaches including benchmarking best practices, designing new processes, revisingorganisational structures and a selection of key processes (8 core and 5 support processes). The BPR has beenprogressively implemented at all levels followed by changes in staff deployment, specific job assignments and therecruitment of new staff.

Health facility construction and expansion - Progress in facility construction, upgrading and equipping underHSDP III has been remarkable. The numbers have reached 14,416 HPs (88.7% of the target); 2,689 HCs (84% of target);and 111 Public Hospitals (125% of target).

Human resource development - Overall, targets have been met for the community level and most of the Mid-Level Health Professionals (MLHPs). However, there are still major gaps for medical doctors, midwives and anaesthesiaprofessionals, especially when considering the long lead time and limited involvement of the private sector in trainingthese professionals.

Pharmaceutical services - In order to improve efficiency in the supply chain of pharmaceuticals and medicalsupplies, PHARMID has been transformed into the Pharmaceutical Fund and Supply Agency (PFSA) and key measures takento strengthen the capacity of the new agency. The PFSA has been able to develop a pharmaceutical forecasting plan inconsultation with health facilities about what would be required for need-based procurement.

Health and health related services and product regulation - A key principle of the health sector BPR is improvingthe quality of health services through institutionalising accountability and transparency. As a part of this, the former DrugAdministration and Control Agency (DACA) has been transformed into the Health and Health related Services and ProductRegulatory Agency with a mandate to undertake inspection and quality control of health and health related products;premises, professionals and health delivery processes in an integrated manner.

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Harmonisation and alignment - Under harmonisation and alignment, the major objective is to have the One-Plan,One-Budget and One-Report approach at all levels of the health system. Ethiopia is a signatory of the Global IHP+ Compactand the first to develop and sign a Country-based IHP+ Compact. One Plan: The health sector wide strategic plan (HSDP)is the product of substantial consultations between the Ministry of Health and the Health Development Partners. One ofthe most important refinements in HSDP III was the inclusion of “Woreda-Based Health Sector Planning”; this planningsystem created a platform for joint planning by all stakeholders at all levels of the health system including healthdevelopment partners. One Budget: Subsequent to signing the IHP+ Compact in 2008, the MOH and health developmentpartners jointly commissioned an independent health system assessment that led to establishment of the MDGPerformance Fund and a Joint Financing Arrangement (JFA) for the Fund that signed by Development Partners, andenabling the MOH to access and make use of pooled funds. One Report/One M&E: As part of the BPR, integratedsupportive supervision, operational research, performance reviews and quality assurance and inspections are nowcomplementing M&E to inform strategic planning of the health sector. Joint Performance reviews such as the annualreview meeting (ARM) and joint review meeting (JRM) are being undertaken according to the plan; the Annual ReviewMeeting (ARM) has been conducted every year.

Governance of HSDP: Key coordinating and steering committees are performing well, including the MOH-RHBsJoint Steering Committee, MOH-HPN Joint Consultative Forum and the Joint Core Coordinating Committee (JCCC). TheJoint Consultative Forum and JCCC meetings have also been regularly functional, with the JCCC focusing on technical andoperational issues.

Health care financing - Over the course of the HSDPs, various background studies on health care financing issueshave contributed to the design and introduction of health financing reforms. The reform components include: retentionand utilisation of revenue, administration of the fee waiver system and establishment of functioning facility governancebodies. Other parts of the reforms have included outsourcing of non-clinical services, establishing private wings in healthfacilities and the exemption of certain services.

Retention and utilisation of revenue - The performance report for health care financing up to the end of fiscalyear 2008/2009 showed that 73 hospitals and 823 health centres have started retaining revenue. Encouragingly, 95% ofthese units collecting user fees had used the revenue at their level.

Health insurance: To date, a draft law and regulation have been revised and presented for policy and technicaldiscussions. A series of consultative discussions have been conducted in Addis Ababa and the regions. The legal frameworkhas been improved and the social health insurance (SHI) Proclamation was approved by the Council of Ministers and byParliament in July 2010. Parallel to the work on social health insurance, various activities have been undertaken to developand pilot community-based health insurance (CBHI). Trend of expenditure in the health sector: Ethiopia’s fourth NationalHealth Accounts study (NHA, 2010) showed that national health expenditures have grown significantly, increasing the percapita health expenditure has increased from USD 7.14 (in 2004/05) to USD 16.09 (in 2007/08).

Pastoralist health service - Pastoralist peoples in Ethiopia constitute about 10% of the national population, andthey have many special health needs that are not completely met by the largely static facility-based health system presentin the rest of the country. This gap prompted MOH to adapt the 16 health Extension program (HEP) packages topastoralists’ needs and translate them into local languages. There is also now a Pastoralist Health Promotion and DiseasePrevention Directorate to focus attention on health of the pastoralist populations.

Operational research - In HSDP III, the BPR resulted in redesigning Research and Technology Transfer as a coreprocess of the MOH. There was a surge in the number of operational studies during HSDP III that covered a wide range ofareas: Child health, Communicable diseases, Public health, Reproductive health, and health services.

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2. ESPA Plus-Census Methodology2.1 Overview

The Ethiopia Service Provision Assessment (ESPA+) consists of two major activities. These are: (1) a nationallevel representative sample survey of government (public) and private functional health facilities with the aim to overseeavailability and readiness of all services and (2) a national level census of all hospitals and health centers with the aim todevelop master health facility list and assess basic infrastructure.

The Ethiopia Service Provision Assessment (ESPA+) had used, two separate teams who were trained and assignedto the respected facilities to collect data for the two assessments. The ESPA+ survey teams were dedicated to collect datafrom all hospitals and representative sample of health centers, private clinics, and health posts. The ESPA Plus-Censusteams were allocated to collect data from all governmental hospitals and health centers irrespective of their operationalstatus. To avoid double visit and to be efficient in resource utilization, ESPA Plus-Census teams were only assigned tofacilities that were not included in the ESPA+ survey.

The 2014 ESPA Plus-Census is the first of its kind to be conducted in Ethiopia. The information will help healthprogramme managers and policy makers to prioritise interventions that will enhance the provision of quality healthservices.

2.2 Institutional framework of the 2014 ESPA Plus-Census

The 2014 Ethiopia Service Provision Assessment Plus-Census was undertaken by the Ethiopian Public HealthInstitute (EPHI). Technical support was provided by ICF International under the MEASURE DHS Project. The United StatesAgency for International Development (USAID), World Bank, UNICEF, Irish Aid and WHO provided the financial support. Atechnical committee was constituted, as part of the ESPA+ survey, to oversee all policy and technical issues related to the2014 ESPA Plus-Census.

2.3 Objectives of the ESPA Plus-Census

The objectives of the 2014 ESPA Plus-Census were to: Provide master facility list existing in the current year that are managed by government. Assess basic resource and support system of health facilities

Data collection instruments were adapted and developed for ESPA Plus-Census to respond to the following basicquestions:

1. To what extent are facilities exist and distributed at national, regional, zonal, and woreda level?

The 2014 ESPA Plus-Census assessed the facility identification with their geographic coordinates for all functionaland nonfunctional governmental hospitals and health centers.

2. To what extent are resources and support systems available in the facilities?

The 2014 ESPA Plus-Census assessed support systems for basic infrastructure, infection control system,management system like external supervision, quality assurance, and HMIS.

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The 2014 ESPA Plus-Census collected data on whether facilities had, basic equipment on general outpatient areaand amenities, including electricity, water, emergency transport, and client latrine. The 2014 ESPA Plus-Census alsoassessed staffing levels. Interviewers asked whether a facility had these support systems in place and noted whether thosewere functioning.

2.4. ESPA Plus-Census content and methods for data collection

2.4.1 Content of the 2014 ESPA Plus-Census

The 2014 ESPA Plus-Census focused on facility identification with their geographical coordinates, general serviceavailability, basic infrastructure, and support system. All the Census questions are the subset of the ESPA+ Surveyinventory questionnaire.

2.4.2 Methods for Data collection

The 2014 ESPA Plus-Census questionnaire was based on facility inventory questionnaire developed for ESPA+survey and adopted by specialists from EPHI and MOH. After preparation of definitive questionnaires in English, theinventory questionnaire was translated into Amharic language. The English and the Amharic version of the inventoryquestionnaire were loaded onto tablet computers, which were used during interviews to ask questions and also recordresponses (computer assisted personal interviewing–CAPI).

2.5 ESPA plus-Census Implementation2.5.1 Data collection instrument

The main data collection tool used for 2014 ESPA Plus-Census was only facility inventory questionnaire from ESPA+survey.

Using the facility inventory questionnaire the interviewers collected information on facility identification andtheir geographic coordinates, availability of specific services, facility infrastructure and support systems. Hence, the personmost knowledgeable about the organisation of the facility and/or the most knowledgeable provider of each service wereinterviewed. If another provider needed to give some specific information, that provider was invited (or visited, ifappropriate) and questioned about that specific information. The questionnaire is organised into the following threemodules:

(1) Module 1 elicits information on general service availability.(2)Module 2 collects information on general facility readiness. Seven sections cover topics such as facilityinfrastructure (sources of water, electricity, etc.), staffing, health management information systems, healthstatistics, processing of instruments for re-use, health care waste management, availability of basic suppliesand equipment, and laboratory diagnostic capacity.(3)Module 3 Solicits information on service-specific readiness. Sections cover child health (child curativecare), and delivery and new born care.

In addition to the above modules, the questionnaire had included facility identification and geographiccoordinates.

2.5.2 Training and Data Collection

Pre-Test

The pre-test for the 2014 ESPA+ took place October 15, 2013–November 13, 2013. Sixteen regional coordinatorsand fourteen interviewers all mostly health providers hired by EPHI were trained as interviewers in the application of the

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questionnaires and computer programmes and also trained as trainers to lead the main training. During pre-test datacollection, health facilities within Oromia region were surveyed for three days to test and refine the survey instrumentsand the computer programmes. After the pre-test, the questionnaires and computer programmes were finalised for themain data assessment. ICF personnel lead the training and staffs from EPHI, MOH and World Bank were also involved inthe training in the area of their expertise.

Main Assessment

The main training for the 2014 ESPA Plus-Census took place January 13 - 22, 2014. Six of the sixteen regionalcoordinators, master level health workers with prior survey experience conducted the main assessment in Amharic. Theeight regional coordinators and fourteen interviewers from the pre-test remained with EPHI to assist in preparation forand during main training as well. EPHI personnel along with ICF international personnel oversaw the training.

Sixty mostly health providers (nurses, nurse midwives, and clinicians) were trained in the application of censusinstruments and computer programmes. The training included classroom lectures and discussion, practicaldemonstrations, mock interviews, role plays, and field practices. The participants were also given daily homework toconduct mock interviews among themselves using the census tools. The first four days of the training were dedicatedexclusively to training of interviewers on use of paper questionnaires. The fifth day was dedicated for paper based fieldpractice to ensure that the participants understood the content of the questionnaires, as well as how to organisethemselves once in a health facility.

During the sixth day of training, participants were first introduced to tablet computers, and then transitioned tothe use of the tablet computers for data collection (CAPI). Participants practiced the questionnaire and CAPI approachesin teams and in pairs; this was done using completed paper questionnaires from the facilities visited during the paperbased field practice. The last two days of the training were dedicated to field practice using computers followed by a oneday discussion on concerns raised from the field practice.

2.5.3. Data collection

Following the training, 29 teams were formed, each consisting of a team leader, an interviewer, and a driver. Twoextra interviewers were dispersed in to two teams. Then Data collection commenced on 23rd January 2014 and endedon 23rd June 2014. The team leader had the responsibility of checking administered questionnaires before leaving eachfacility. Each team was given a list of facilities to visit, giving the facilities’ names, types, and locations. But, if the teamfinds a new facility, it will be included in the existing list. The team leader made arrangements with the management ofthe facilities to be visited next at least one day before the visits so that managers could prepare to receive the interviewers.

On average, data collection took half a day per facility. Every effort was made for teams to visit facilities on dayswhen services being assessed would be offered. Whenever any of the services of interest was not being offered on theday of the visit, the teams returned on a day when the service would be offered to observe. If, however, the service wasoffered on the day of the visit, the teams did not revisit the facility.

Each interviewer ensured that the respondent for each component of the facility inventory was the mostknowledgeable person for the particular service or system component being assessed. Informed consent was obtainedfrom the facility in-charge, from all respondents for the facility inventory questionnaires. Where required by thequestionnaires, the interviewer indicate whether a specific item being assessed was observed, reported not seen or notavailable. Equipment, supplies, and resources for specific services were recorded as available only if they were observedor reported not seen in the relevant service delivery area or in an immediately adjacent room.

Fieldwork supervision was coordinated by EPHI. TWG members, MOH staff, EPHI staff, World Bank and ICFpersonnel participated in supportive fieldwork supervision. Six regional coordinators were each assigned four to five teamsto supervise. They made periodic visits to their teams to review work and monitor data quality. The menu’s created for

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supervisor; regional coordinator and central office were used to check the quality of data. Field-check tables generatedby the office editors were also used to check the quality of the collected data.

2.5.4 Data management and cleaning

Data management and analysis were carried out as follows: Management of questionnaires in the field. After completing data collection for each facility, the interviewers

reviewed the questionnaires before handing them over to the team leader, who reviewed them a second time. Theteam leader then creates a zip file data for each facility and passed on to the regional coordinators and office editor,via outlook email created by EPHI, IT staffs.

Data flow. Once the zipped file for each facility received at central office through outlook email, the office editorswere extracting and put in to the right directory. The data was then edited to eliminate any mistakes that wouldprevent the computer from accepting information during data processing. In cases where there was a problem withthe data from a facility, the data collection team was consulted so that the problem could be rectified. In someextreme cases the facility questionnaire could be returned to the team to check the data.

Data processing and cleaning. Data cleaning included the checking of range, structure and a selected set of checks forinternal consistency. All errors detected during machine editing were corrected. Technical assistance for the dataediting programs were furnished by ICF International. All data entry and editing programs were written using CSPro.

The design of the tabulation plan and the preparation of the programmes for producing statistical tables werecarried out from August through September 2014. The analysis plan was revised on the basis of feedback from the ESPA+survey management team.

2.5.5. Data Analysis

Unless otherwise indicated, the 2014 ESPA Plus-Census considered only those items observed by the interviewersthemselves to be available.

2.6 Facilities assessed by the ESPA Plus-Census

A master list of 23,102 formal sector health facilities in Ethiopia was obtained from the Federal Ministry of Health.The list included: 202 hospitals, 3,292 health centres, 15, 618 health posts, and 3,990 private clinics (higher clinics, Mediumclinics and lower clinics). These facilities were managed by the following authorities: the government, other governmental(military, prison, federal police), private for profit, and nongovernmental organisation (NGOs (mission/faith based, nonprofit)).

As it was stated before, the main objective of the ESPA Plus-Census is to develop master facility list of allgovernmental health facilities, however; due to financial and time constraints the study had covered only governmentalhospitals and health centers. Accordingly, the 2014 ESPA Plus-Census assessed 3,820 facilities, except two health centersfrom Somali and SNNP regions due to security problem. In addition, to complete the master health facility list of allgovernmental facilities, the ESPA+ Plus-Census questionnaire was able to capture the list of 15, 491 satellite health postswhich makes a total of 19,311 governmental facilities (See Annex B).

Table 2.1 presents distribution of all facilities (functional and nonfunctional) of each type by region. As shown inthe Table 2.1 there are a total of 3,820 health facilities in the country where 36 referral hospitals, 73 General hospitals,166 primary hospitals, and 3,545 health centers.

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Table 2.1 Distribution of facilities, by region

Table 2.1 Distribution of facilities, by region

Number of facilities of each type by region, Ethiopia SPA Plus-Census 2014

Region

Tigray Afar Amhara Oromia SomaliBenishangulGumuz SNNP Gambella Harari

AddisAbaba

DireDawa Total

Facility type

ReferralHospital 1 1 5 7 1 0 5 1 1 13 1 36GeneralHospital 14 3 4 31 8 2 10 0 1 0 0 73PrimaryHospital 16 2 64 63 1 4 13 2 0 0 1 166Health Center 213 78 849 1,317 165 40 731 32 8 97 15 3,545

Total 244 84 922 1,418 175 46 759 35 10 110 17 3,820

Figure 2.1 shows the number of primary hospitals by operational status. Of them, 27 are fully functional i.e., noconstruction or expansion ongoing, 13 fully functional, but currently under expansion, 4 partially functional currentlyunder expansion, and 122 non functional primary hospitals.

Figure 2.1 Number of Primary, General, and Referral Hospitals, by their operational status, ESPA Plus-Census 2014.

Figure 2.2 shows operational status of Health centers. Of all health centers 3,101 facilities are fully functional i.e.,no construction or expansion ongoing, 168 fully functional i.e., currently under expansion, 46 partially functional i.e.,currently under expansion, and 230 not functional i.e., currently under construction.

166

73

36

27

48

19

13

23

11

4

0

1

122

2

5

PrimaryHospitals

GeneralHospitals

ReferalHospitals

Not functional, currently underconstruction

Partially functional, currentlyunder Expansion

Fully functional, currentlyunder expansion

Fully Functional, Noconstruction or expansion

Total

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Figure 2.2 Number of Health centers, by their operational status, ESPA Plus-Census 2014.

Table 2.2 presents the percent distribution of the facilities and the results following attempts to visit thosefacilities. Some facilities on the list were not yet operational (9 percent). As a result, data were successfully collected froma total of 3,420 facilities, representing 91 percent of those on the list.

Table 2.2 Result of visited facilities, by background characteristics

Table 2.2 Result of visited facilities, by background characteristics

Percent distribution of facilities according to result of visit to the facility, by background characteristics, Ethiopia SPA Plus-Census 2014

Background characteristicsInterview

Completed

Respondent

not availableNot yet

operational Other Total percent Number of facilities

Facility type

Referral Hospital 86 0 14 0 100 36

General Hospital 97 0 3 0 100 73

Primary Hospital 27 0 73 0 100 166

Health Center 93 0 7 0 100 3,545

Region

Tigray 98 0 2 0 100 244

Afar 76 1 23 0 100 84

Amhara 89 0 11 0 100 922

Oromia 91 0 9 0 100 1,418

Somali 85 0 15 0 100 175

Benishangul Gumuz 74 0 26 0 100 46

SNNP 94 0 6 0 100 759

Gambella 86 0 14 0 100 35

Harari 100 0 0 0 100 10

Addis Ababa 77 0 23 0 100 110

Dire Dawa 100 0 0 0 100 17

Urban/rural

Urban 88 0 12 0 100 1,334

3,545

3,101

168

46

230

Healthcenters

Not functional, currently underconstruction

Partially functional, currentlyunder construction

Fully functional, currently underexpansion

Fully Functional, Noconstruction or expansion

Total

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Rural 92 0 8 0 100 2,486

Total 91 0 9 0 100 3,820

Note: some of the rows may not add up to 100 percent due to rounding

Table 2.3 presents the percent distribution by background characteristics of the facilities that were successfullyassessed. The majority of facilities in the country excluding health posts are health centers (96 percent). Hospitals (4percent) are the fewest in number.

Oromia region contain the largest proportion of the facilities (37 percent) managed by government followed byAmhara and SNNP regions which contain about one-fourth of the facilities each (24 percent and 21 percent respectively).The majority of health facilities that are managed by government are located in rural area (66 percent) of the country.

Table 2.3 Distribution of facilities, by background characteristics

Table 2.3 Distribution of facilities, by background characteristics

Percent distribution and number of facilities, by background characteristics,Ethiopia SPA Plus-Census 2014

Background characteristicsPercent distribution offacilities Number of facilities

Facility typeReferral Hospital 1 31General Hospital 2 71Primary Hospital 1 44Health Center 96 3,314

RegionTigray 7 240Afar 2 64Amhara 24 824Oromia 37 1,294Somali 4 149Benishangul Gumuz 1 34SNNP 21 713Gambella 1 30Harari 0 10Addis Ababa 2 85Dire Dawa 0 17

Urban/ruralUrban 34 1,177Rural 66 2,283

Total 100 3,460

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3. Facility-level infrastructure and resourcesBackground

Although health care services can be offered under a variety of conditions, some common elements of the healthsystem ensure their quality, acceptability, and utilization. This chapter looks at the extent to which government managedhealth facilities in Ethiopia have the following resources, management, and support systems at the facility level:

Availability of specific of services Facility infrastructure to support service delivery and utilization Basic equipment availability Capacity for processing of equipment for reuse Standard infection prevention supplies Waste Management Laboratory service capacity Management systems to support and maintain quality servies Staffing pattern, and Routine user fees

3.1 Availability of Specific Services

Tables 3.1 present information on the overall availability of specific services. The comprehensive inventory of theavailable specific services contributes to use of service.

Table 3.1 Availability of specific services

Table 3.1 Availability of specific services

Among all facilities, the percentages and numbers that offer specific services, Ethiopia SPA Plus-Census2014

Service provided

Percentage offacilities offering

serviceNumber of facilities

offering service

Antenatal care services 99 3,440Normal delivery1 99 3,418Diagnosis or treatment of malaria2 68 2,351Diagnosis or treatment of STIs, excluding HIV3 97 3,365Diagnosis, treatment prescription or follow-up for TB4 59 2,037HIV testing and counselling (HTC) services5 67 2,306Minor surgical services6 96 3,308Laboratory diagnostic services 79 2,718Emergency services 100 3,454Inpatient services 52 1,796

Total - 3,460

5 Facility reports that is has the capacity to conduct HIV testing in the facility, either by rapid diagnostictesting or ELISA, and an unexpired HIV rapid diagnostic test kit is available in the facility on the day ofthe survey, or other test capability is available

4 Facility reports that providers assigned to the facility diagnose TB, prescribe treatment for TB, orprovide TB treatment follow-up services for clients put on treatment elsewhere.

2 Facility reports that it offers malaria diagnosis and/or treatment services. Also, facilities offeringcurative care for sick children where providers of sick child services were found on the day of the surveyto be making diagnosis of malaria or offering treatment for malaria were counted as offering malariadiagnosis and/or treatment services.1 Normal delivery refers to a birth that is vaginal, spontaneous in onset, low-risk at the start of labor,and remaining so through labor and delivery. Delivery services are almost always with newborn careservices, which refer to treatment received by a newborn child from the date of birth and for the first

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four weeks of life.3 These include any service to diagnose or treat sexually transmitted infections, infections, excluding HIVinfection.6 These are defined as any situation that requires suture, incision, excision, manipulation, or proceduresthat can be performed in the general OPD and not requiring the use of a surgical theatre. Examplesinclude incision and drainage of an abscess, suturing of cuts, etc.

Emergency services (100 percent), antenatal care and normal delivery services (each 99 percent), diagnosis ortreatment of STIs excluding HIV (97 percent), and minor surgical services (96 percent respectively) are available in almostall government hospitals and health centers. Diagnosis, treatment prescription or follow-up for TB, and inpatient servicesare the least likely available services (59 and 52 percent respectively).3.2 Basic Amenities for Client Services

Although good services can be provided in minimal service delivery settings, both clients and providers are morelikely to be satisfied with a facility that has basic amenities and infrastructure such as a regular source of electricity, supplyof improved water, and basic sanitation. Tables 3.2 present information on availability of basic amenities.

Table 3.2 Availability of basic amenities

Table 3.3 Availability of basic amenities for client services

Among all facilities, the percentages with indicated amenities considered basic for quality services, by background characteristics, Ethiopia SPA Plus-Census 2014

Amenities

Backgroundcharacteristics

Regularelectricity1

Connectedto powergrid only9

Improvedwater

source2

PipedWateronly 10

Visual andauditoryprivacy3

Clientlatrine4

Communicationequipment5

InternetAccess6

Averagetravel time

to theambulancestation inminutes8

denom forcolumn 10

Number offacilities

Facility typeReferral Hospital 100 100 97 97 97 97 87 65 5 3 31General Hospital 92 94 90 87 93 94 79 44 18 11 71Primary Hospital 86 93 91 89 100 82 73 36 5 13 44Health Center 45 53 65 42 90 80 15 2 42 2,417 3,314

RegionTigray 53 74 74 48 98 68 29 5 35 180 240Afar 56 52 47 38 100 91 31 9 37 27 64Amhara 52 55 64 38 96 77 15 3 50 486 824Oromia 38 51 64 48 82 87 16 2 36 1,033 1,294Somali 63 34 54 30 97 91 5 3 79 44 149BenishangulGumuz 59 68 76 32 94 85 18 3 64 12 34

SNNP 47 51 69 41 93 73 11 3 46 569 713Gambella 60 30 83 33 93 83 3 0 48 16 30Harari 70 80 80 70 80 100 80 10 11 6 10Addis Ababa 61 96 99 99 95 94 91 31 22 64 85Dire Dawa 94 82 88 88 94 100 76 35 20 7 17

Urban/ruralUrban 55 89 89 80 89 87 38 9 18 635 1,177Rural 43 37 54 26 91 78 7 1 50 1,809 2,283

Total 47 54 66 44 90 81 18 4 42 2,444 3,460

Note: The indicators presented in this table comprise the basic amenities domain for assessing general service readiness within the health facility assessmentmethodology proposed by WHO and USAID (WHO 2012).1 Facility is connected to a central power grid and there has not been an interruption in power supply lasting for more than two hours at a time during normalworking hours in the seven days before the survey, or facility has a functioning generator or invertor with fuel available on the day of the survey, or else facility hasback-up solar power.2 Water is piped into facility or piped onto facility grounds or bottled water is used, or else water from a public tap or standpipe, a tube well or borehole, a protecteddug well, protected spring, or rain water, and the outlet from this source is within 500 meters of the facility.

3 A private room or screened-off space available in the general outpatient service area that is a sufficient distance from other clients so that a normal conversationcould be held without the client being seen or heard by others.

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4 The facility had a functioning flush or pour-flush toilet, a ventilated improved pit latrine, pit latrine with slab, or composting toilet.5 The facility had a functioning land-line telephone, a functioning facility-owned cellular phone or wireless telephone, a private cellular phone that is supported by

the facility, or a functioning short wave radio available in the facility.6 The facility had a functioning computer with access to the internet that is not interrupted for more than two hours at a time during normal working hours, orfacility has access to the internet via a cellular phone inside the facility.7 The facility had a functioning ambulance or other vehicle for emergency transport that is stationed at the facility and had fuel available on the day of the survey, orfacility has access to an ambulance or other vehicle for emergency transport that is stationed at another facility or that operates from another facility.

8 For facilities with access to an ambulance or other vehicle for emergency transport that is stationed at another facility or that operates from another facility, thetime taken (in minutes) to travel from the facility to the ambulance station on different road types (all weather road, dry weather road, foot path/rail) by differentmode of transport (car, cart, foot, or motorcycle).9 Facility is connected to a central power grid10 Water is piped into facility or piped onto facility grounds

In general, a little under half (47 percent) of all facilities have regular, uninterrupted electricity (i.e., the facility isconnected to a central power grid, or has solar power or both, and power is routinely available during regular servicehours), or has a functioning generator with fuel. As expected, all hospitals regardless of type (87 to 100 percent) are morelikely than health centers (45percent) to have regular, uninterrupted electricity.

In general, two-third of all facilities have an improved water source in the facility (i.e., water is piped into thefacility or onto facility grounds, or else water is from a public tap or standpipe, a tube well or borehole, a protected dugwell, or protected spring, or rain water, or bottle water), and the outlet from this source is within 500 metres of the facility.However, health centers are less likely to have an improved water source (65percent) than other types of facilities.

On average, more than eight of every ten facilities (81percent) have a functioning client latrine (i.e., the facilityhad a functioning flush or pour-flush toilet, a ventilated improved latrine, pit latrine with slab), or else the facility hascomposting toilet.

Only 4 percent of all facilities have computer with internet (i.e., the facility had a functioning computer with accessto the internet that is not interrupted for more than two hours at a time during normal working hours), or else facility hasaccess to internet via a cellular phone inside the facility which is supported by the facility. Facilities in Dire Dawa (35percent) and Addis Ababa (30 percent) city administrations are more likely to have computer with internet than otherregions.

Overall, transport for emergencies is available in 84 percent of all facilities (i.e., the facility has a functioningambulance or other vehicle for emergency transport that is stationed at the facility and had fuel available on the day ofthe survey), or else the facility has access to an ambulance or other vehicle stationed at or operating from another facility.

Among all government hospitals and health centers, 42 minutes is the average travel time from the health facilityto the ambulance station on different road types by different mode of transport. It takes an average of 5 minutes forhospitals. In Somali region, an average of over one hour is required to reach an ambulance station (79 minutes for allhealth facilities).

3.3 Availability of basic equipment

The 2014 ESPA Plus-Census also assessed the availability of equipment and supplies necessary for evaluating thestatus of general outpatient service area for providing preventive interventions. Table 3.3 summarises information onthese items by background characteristics.

Overall, 61, 25, and 17 percent of all hospitals and health facilities at general outpatient service area have adult,child, and infant scale respectively. Stethoscope (96 percent) and blood pressure apparatus (89 percent) are widelyavailable basic equipment at the general outpatient area.

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Six of every ten facilities at general outpatient service area have thermometer. Among all hospitals and healthcenters, measuring tape for head circumference and light source are the least likely available basic equipment at generaloutpatient service area (each 13 percent).

Table 3.3 Availability of basic equipment in the general outpatient service area

Table 3.3 Availability of basic equipment in the general outpatient service area

Among all facilities, the percentages with equipment considered basic to quality client services available in the general outpatient service area, by backgroundcharacteristics, Ethiopia SPA Plus-Census 2014

Equipment

Backgroundcharacteristics Adult scale

Childscale1

Infantscale2

Stadio meter(or heightRod) formeasuringheight

Measuring tape(for headcircumference) Thermometer Stethoscope

Bloodpressureapparatus3

Lightsource4

Number offacilities

Facility typeReferral Hospital 77 35 29 65 35 84 100 100 39 31General Hospital 67 36 26 44 26 74 99 93 32 71Primary Hospital 73 36 29 44 44 73 100 96 40 44Health Center 61 24 17 45 12 59 95 89 12 3,314

RegionTigray 69 57 42 64 30 86 93 88 20 240Afar 73 39 38 58 14 67 97 88 9 64Amhara 56 18 11 42 9 61 95 86 14 824Oromia 57 23 15 42 11 50 96 90 9 1,294Somali 66 14 5 34 7 54 98 90 15 149Benishangul Gumuz 62 29 18 47 24 56 94 88 12 34SNNP 72 26 21 51 18 66 96 90 12 713Gambella 83 40 23 63 17 83 97 77 10 30Harari 40 10 30 20 20 40 100 100 20 10Addis Ababa 35 14 12 24 16 66 97 97 40 85Dire Dawa 65 18 29 59 12 88 100 94 24 17

Urban/ruralUrban 58 24 17 41 14 54 95 90 14 1,177Rural 63 25 17 47 13 63 96 88 12 2,283

Total 61 25 17 45 13 60 96 89 13 3,460

Note: The indicators presented in this table comprise the basic equipment domain for assessing general service readiness within the health facility assessmentmethodology proposed by WHO and USAID (WHO 2012).

1 A scale with gradation of 250 grams, or a digital standing scale with a gradation of 250 grams or lower where an adult can hold a child to be weighed, availablesomewhere in the general outpatient area

2 A scale with gradation of 100 grams, or a digital standing scale with a gradation of 100 grams where an adult can hold an infant to be weighed, availablesomewhere in the general outpatient area

3 A digital blood pressure machine or a manual sphygmomanometer with a stethoscope available somewhere in the general outpatient area4 A spotlight source that can be used for client examination or a functioning flashlight available somewhere in the general outpatient area.

3.4 Systems for infection control

Universal precautions refer to infection control measures that can prevent cross-infection from blood and otherbody fluids. All health workers who may come into contact with body fluids should exercise these universal precautions,working under the assumption that anyone may have an infectious condition (CDC, 1987; JHPIEGO, 2003).

The 2014 ESPA Plus-Census assessed conditions for infection control in outpatient service area. The censusexamined conditions to see whether providers could reasonably be expected to wash their hands between seeing differentclients. It also checked for the presence of a box for secure disposal of sharp items such as disposable needles, which maybe contaminated with HIV or other blood borne infections.

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Summary information on capacity to process equipment for reuse is presented in Tables 3.4 and aggregateinformation on infection control measures available in general outpatient area are presented in Table 3.4 and Table 3.4.

3.4.1 Capacity for processing of equipment for reuse

For most equipment that is used for client examination, either sterilisation or high-level disinfection (HLD)procedures are sufficient to prevent the spread of infection. However, to effectively kill the spores that cause illnessessuch as tetanus, either dry-heat sterilisation or an autoclave system (or the less frequently used chemical sterilisation withformaldehyde or glutaraldehyde) is required. This type of system is necessary for processing surgical equipment that willbe reused, such as blade handles and scissors used to cut the umbilical cord. Depending on the size of the facility, differenttypes of equipment may be processed using different methods or at more than one site in the facility. The informationpresented in this chapter refers to the primary site in the facility where equipment is processed.

Nine of every ten facilities have functioning equipment (including the necessary chemicals for HLD) for theprocessing method used (Table 3.4). All hospitals (100 percent) and majority of health centres (93percent) havefunctioning equipment. At the regional level, the availability of functioning equipment ranges from 100 percent in DireDawa City Administration and 99 percent in Tigray to 63 percent in Afar region (Table 3.4).

Two-third of all facilities has functioning equipment as well as the correct knowledge of the processing time andtemperature for the method (see Table 3.4). When presence of an automatic timer is added to the assessment (whereapplicable), the proportion declines to 27 percent of all facilities. Written guidelines for sterilisation or HLD processing inany service area were found in only 12 percent of all facilities.

Table 3.4 Capacity for processing of equipment for reuse

Table 3.4 Capacity for processing of equipment for reuse

Percentage of facilities with the equipment and other items to support the final processing of instruments for reuse, by background characteristics, Ethiopia SPAPlus-Census 2014

Percentage of facilities having:

Background characteristics Equipment 1

Equipmentand knowledgeof process time2

Equipment,knowledge of process

time, and automatic timer 3Written guidelines

for sterilization or HLD 4 Number of facilities

Facility typeReferral Hospital 100 94 81 35 31General Hospital 100 85 63 31 71Primary Hospital 100 87 80 40 44Health Center 93 65 25 11 3,314

RegionTigray 99 88 43 40 240Afar 63 39 27 11 64Amhara 93 64 25 10 824Oromia 93 67 24 6 1,294Somali 83 58 22 5 149Benishangul Gumuz 91 47 18 18 34SNNP 95 66 28 17 713Gambella 90 53 10 0 30Harari 80 60 60 20 10Addis Ababa 93 72 58 24 85Dire Dawa 100 53 53 41 17

Urban/ruralUrban 97 68 39 19 1,177Rural 91 65 21 9 2,283

Total 93 66 27 12 3,460

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1 Facility reports that some equipment is processed in the facility and facility has a functioning electric dry heat sterilizer, a functioning electric autoclave, a non-electric autoclave with a functioning heat source, an electric boiler or steamer, or a non-electric boiler or steamer with a functioning heat source available anywherein the facility or high level disinfectant that are used for sterilization or high level disinfection of equipment for reuse

2 Processing area has functioning equipment and power source for processing method and the responsible worker reports the correct processing time (orequipment automatically sets the time) and processing temperature (if applicable) for at least one method. Definitions for capacity for each method assessed were afunctioning equipment and the following processing conditions:· Dry heat sterilization: Temperature at 160°C and processed for at least 120 minutes, or temperature at least 170°C and processed for at least 60 minutes.

· Autoclave: Temperature at 121°C under 106KPas pressure; wrapped items processed for at least 30 minutes; unwrapped items processed for at least 20 minutes· Boiling or steaming: Items processed for at least 20 minutes.· Chemical high-level disinfection: Items processed in chlorine-based or glutaraldehyde or formaldehyde solution and soaked for at least 20 minutes3 An automatic timer here refers to a passive timer that can be set to indicate when a specified time has passed. It may be part of the sterilization process or the

HLD equipment.4 Hand-written instructions that are pasted on walls and which clearly outline the procedures to follow for processing of equipment are acceptableNote: According to MOH National Infection Prevention guidelines the temperature and time relationship for dry heat sterilization is set to be as follows:· Temperature at 160°C and processed for at least 120 minutes.· Temperature at 170°C and processed for at least 60 minutes.Autoclave:· Temperature at 121°C under 106KPas pressure wrapped items processed at least for 30 minutes.· Temperature at 121°C under 106KPas pressure unwrapped items processed at least for 20 minutes.

3.4.2 Standard precautions for infection prevention

Infections acquired in health facilities often complicate the delivery of health care worldwide. Strict compliancewith infection control guidelines and constant vigilance are necessary to prevent such infections. The items consideredrelevant and necessary to prevent these infections include soap, running water, disinfectant, sharps boxes for appropriatedisposal of sharps waste, disinfectant solution, and gloves. The presence of running water in the general outpatient areadoes not necessarily imply that providers will wash their hands, or how and when they should. However, having runningwater and soap available in the area where services are provided, or in an immediately adjacent area, may increase thelikelihood that they will do so.

The 2014 ESPA Plus-Census assessed conditions for infection control in general outpatient area. As shown in Table3.5.1, fifty-nine percent of all facilities had sterilization equipment excluding the necessary chemicals for HLD (i.e.,instruments are processed in the facility and the facility has a functioning electric dry heat sterilizer, a functioning electricautoclave, or a non electric autoclave with functioning heat source available somewhere in the facility). Almost allhospitals (96-100 percent) are more likely to have these sterilization equipment than health centers (57 percent).

Individually, an average of 16 percent had soap, 26 percent had running water, and 21 percent of all facilities hadalcohol-based hand disinfectant. Among all the facilities twenty-six percent of all facilities had soap and running wateror else hand disinfectant. This suggests that service providers in three-quarter of facilities either use other sources ofwater to wash their hands (such as water in a basin, which is usually used multiple times) or simply do not wash theirhands while providing outpatient service.

Table 3.5.1 Standard precautions for infection control

Table 3.5.1 Standard precautions for infection control

Percentages of facilities with sterilization equipment somewhere in the facility and other items for standard precautions available in the general outpatient area ofthe facility on the day of the visit, by facility type and Urban/Rural, Ethiopia SPA Plus-Census 2014

Facility type Urban/rural

ItemsReferralHospital General Hospital Primary Hospital Health Center Urban Rural Total

Sterilization equipment1 100 99 96 57 81 48 59Equipment for high-level disinfection 2 61 76 89 67 64 69 67Safe final disposal of sharps waste3 65 75 76 68 70 67 68

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Safe final disposal of infectious waste 4 74 74 71 63 65 63 63Appropriate storage of sharps waste 5 3 0 0 3 3 0 3Appropriate storage of infectious waste 6 0 0 0 1 1 0 1Disinfectant7 90 85 78 25 37 23 28Syringes and needles 8 74 67 33 17 18 19 19Soap 81 63 1 14 27 11 16Running water 9 84 69 60 24 41 18 26Soap and running water 74 56 47 11 23 7 13Alcohol-based hand disinfectant 90 74 71 19 32 15 21Soap and running water or else alcohol-basedhand disinfectant 94 82 78 24 39 20 26Latex gloves 10 97 92 89 43 55 40 45Medical masks 65 40 24 4 11 3 6Gowns 97 90 91 84 90 82 85Eye protection 19 14 11 2 4 2 2Guidelines for standard precautions 11 29 18 18 6 12 5 7

Number of facilities 31 71 44 3,314 1,177 2,283 3,460

Note: The indicators presented in this table comprise the standard precautions domain for assessing general service readiness within the health facility assessmentmethodology proposed by WHO and USAID (WHO 2012).

1 Facility reports that some instruments are processed in the facility and the facility has a functioning electric dry heat sterilizer, a functioning electric autoclave, ora non-electric autoclave with a functioning heat source available somewhere in the facility.2 Facility reports that some instruments are processed in the facility and the facility has an electric pot or other pot with heat source for high-level disinfection byboiling or high-level disinfection by steaming, or else facility has chlorine, formaldehyde, CIDEX, or glutaraldehyde for chemical high-level disinfection availablesomewhere in the facility on the day of the survey.

3 The process of sharps waste disposal is incineration and the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes ofsharps waste by means of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected area priorto removal offsite.

4 The process of infectious waste disposal is incineration, and the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes ofinfectious waste by means of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected areaprior to removal offsite.

5 Sharps container observed in general outpatient service area, in area where HIV testing is done if facility does HIV testing, as well as in area where minor surgeryis done, if facility does minor surgeries

6 Waste receptacles observed in general outpatient service area, in area where HIV testing is done if facility does HIV testing, as well as in area where minor surgeryis done, if facility does minor surgeries

7 Chlorine-based or other country-specific disinfectants used for environmental disinfection available in the general outpatient area8 Single-use standard disposable syringes with needles or else auto-disable syringes with needles available in the general outpatient area9 Piped water, water in bucket with specially fitted tap, or water in pour pitcher available in the general outpatient area10 Non-latex equivalent gloves are acceptable.11 Any guideline for infection control in health facilities available in the general outpatient area

The survey further looked for the availability of guidelines on standard precautions. As evident from Table 3.5.1,the majority of facilities in the country do not have infection prevention guidelines. Indeed, only 7 percent of facilitieshave guidelines or standard precautions at the general outpatient area.

Table 3.5.2 Standard precautions for infection control

Table 3.5.2 Standard precautions for infection control

Percentages of facilities with sterilization equipment somewhere in the facility and other items for standard precautions available in the general outpatient area ofthe facility on the day of the visit, by region, Ethiopia SPA Plus-Census 2014

Region

Items Tigray Afar Amhara Oromia SomaliBenishangulGumuz SNNP Gambella Harari

AddisAbaba Dire Dawa Total

Sterilizationequipment1 77 42 56 56 36 59 65 20 80 85 100 59Equipment forhigh-leveldisinfection 2 85 30 63 69 58 53 72 77 30 57 41 67Safe final disposalof sharps waste3 78 42 68 66 71 76 73 43 80 52 82 68Safe final disposalof infectious waste4 81 50 62 56 70 76 74 57 70 51 76 63

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Disinfectant5 43 41 27 23 20 53 24 40 60 78 76 28Syringes andneedles 6 20 53 25 15 18 29 11 53 30 28 41 19Soap 33 22 21 10 13 29 11 10 60 57 29 16Running water 7 41 20 27 24 28 50 18 17 40 52 53 26Soap and runningwater 30 11 16 8 11 24 7 3 40 48 29 13Alcohol-based handdisinfectant 42 39 18 18 20 38 14 13 30 72 59 21Soap and runningwater or elsealcohol-based handdisinfectant 52 45 27 21 24 41 18 13 70 80 59 26Latex gloves 8 62 66 57 39 40 53 30 60 80 90 100 45Medical masks 15 19 5 4 5 15 3 10 10 28 12 6Gowns 91 59 96 78 72 91 88 43 100 94 82 85Eye protection 3 13 3 1 2 12 1 7 10 12 6 2Guidelines forstandardprecautions 9 23 13 6 3 1 15 8 3 30 16 41 7

Number of facilities 240 64 824 1,294 149 34 713 30 10 85 17 3,460

Note: The indicators presented in this table comprise the standard precautions domain for assessing general service readiness within the health facility assessmentmethodology proposed by WHO and USAID (WHO 2012).1 Facility reports that some instruments are processed in the facility and the facility has a functioning electric dry heat sterilizer, a functioning electric autoclave, or anon-electric autoclave with a functioning heat source available somewhere in the facility.2 Facility reports that some instruments are processed in the facility and the facility has an electric pot or other pot with heat source for high-level disinfection byboiling or high-level disinfection by steaming, or else facility has chlorine, formaldehyde, CIDEX, or glutaraldehyde for chemical high-level disinfection availablesomewhere in the facility on the day of the survey.

3 The process of sharps waste disposal is incineration and the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes ofsharps waste by means of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected area priorto removal offsite.

4 The process of infectious waste disposal is incineration, and the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes ofinfectious waste by means of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected areaprior to removal offsite.5 Chlorine-based or other country-specific disinfectants used for environmental disinfection available in the general outpatient area

6 Single-use standard disposable syringes with needles or else auto-disable syringes with needles available in the general outpatient area7 Piped water, water in bucket with specially fitted tap, or water in pour pitcher available in the general outpatient area8 Non-latex equivalent gloves are acceptable.9 Any guideline for infection control in health facilities available in the general outpatient area

3.4.3 Waste management

Hazardous waste includes infectious waste (such as bandages and cotton balls that is contaminated by blood orother bodily fluids) and sharps waste (such as needles and syringes, blades and ampoules). Appropriate final disposal ofhazardous waste is another important aspect of infection control. The most effective means for hazardous waste disposalis incineration and subsequent burial of the residue. Burying items in deep pits is also an effective means of disposal.When assessing whether facilities have adequate waste disposal systems, the most important issue is verifying that thereis a disposal process that eliminates the possibility of contamination through contact. If the waste is visible and notprotected from animals or people, either before or after being removed, burned, or buried, there is an increased chancethat people might inadvertently come in contact with it, risking infection. Details on waste management are provided inTable 3.6 and also in Figure 3.1 and Figure 3.2.

Availability of incinerator and placenta pit is 55 and 83 percent at the facilities. Amenities that help in managementof liquid wastes like Septic tank or soak away pit or procolation ditch or collection tank are available in 61 percent of thefacilities. Availability of guidelines for health care waste management are observed in only 16 percent of all hospitals andhealth centers.

Table 3.6 Waste management

Table 3.6 Waste management

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Among all facilities, the percentages with facilities to manage all type of medical wastes, by background characteristics, Ethiopia SPA Plus-Census 2014

Percentage of facilities having:

Backgroundcharacteristics Incinerator Placenta pit

Septic tank, soak awaypit, percolation ditch orcollection tank formanagement of liquidwaste Sewage line

Written guidelinesfor health carewastemanagement Trained staff Number of facilities

Facility typeReferral Hospital 61 77 77 81 65 23 31General Hospital 69 94 86 79 65 35 71Primary Hospital 76 100 80 80 47 31 44Health Center 55 83 60 60 14 8 3,314

RegionTigray 70 96 74 76 56 19 240Afar 34 80 42 50 13 13 64Amhara 48 78 47 49 14 10 824Oromia 57 84 72 71 8 5 1,294Somali 68 80 40 26 5 7 149Benishangul Gumuz 62 85 41 56 35 21 34SNNP 54 83 56 59 17 6 713Gambella 37 60 47 40 3 7 30Harari 60 80 80 70 60 50 10Addis Ababa 52 93 81 85 31 36 85Dire Dawa 82 100 88 76 65 53 17

Urban/ruralUrban 62 91 70 68 29 19 1,177Rural 52 79 56 58 9 4 2,283

Total 55 83 61 61 16 9 3,460

After determining which system each facility used, data collectors went either to the location where waste isstored prior to disposal or to the disposal site itself to assess whether there was potentially hazardous waste that was notprotected.

Infectious wasteThe disposal system for infectious waste is considered safe if infectious waste disposal is incinerated, and the

facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes of infectious waste bymeans of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storagein a protected area prior to removal offsite. By these criteria, 63 percent of facilities have safe final disposal system forinfectious waste (See Table 3.5.1).

Figure 3.1 show waste disposal method for infectious waste.

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Figure 3.1 Waste disposal method for infectious waste, Ethiopia SPA Plus-Census 2014 (N=3,460)

Note: “Other” responses are not included.

Sharps wasteThe disposal system for sharp waste is considered safe if sharps waste is incinerated and the facility has a

functioning incinerator with fuel on the day of survey, or else the facility disposes of sharps waste by means of openburning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protectedarea prior to removal offsite. About 68 percent of facilities have safe final sharp waste disposal system (see Table 3.5.1).

Figure 3.2 show waste disposal method for sharp waste.

Figure 3.2 Waste disposal methods for sharp waste, Ethiopia SPA Plus-Census 2014 (N=3,460)

Note: The bars may not add up to 100 percent due to rounding “Other” responses are included.

3.5 Laboratory Diagnostic Capacity

The capacity of a health facility to conduct laboratory diagnostic test enhance greatly the level of service provision.Health facilities do not necessarily require the availability of a specific or designated laboratory building, but the merepresence of tests in the facility including the availability of reagents and equipment needed for each test depending onthe level of the facility type.

35

24

36

3

2

Burned in incinerator in facility

Burned unprotected on flat groundin facility

Burned on protected ground or in pitin facility

Unprotected area in facility withoutburning

Protected area in facility without burning

Percentage of facilities

1

75

9

11

1

1

1

Removed offsite, protected storage

Burned in incinerator in facility

Burned unprotected on flat ground…

Burned on protected ground or in pit…

Unprotected area in facility without…

Protected area in facility without burning

Other responses

Percentage of facilities

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Table 3.7.1 and 3.7.2 present information on availability of basic and advanced level diagnostic test capacity inthe facility by background characteristics and region respectively. But consider that ESPA Plus-Census does not assessregional laboratories and diagnostic centers.

In general, the capacity of a health facility to conduct laboratory diagnostic test, even the basic tests, is low. Aboutsix of every ten facilities have the capacity to conduct malaria diagnostic test (68 percent), urine protein (61 percent),urine glucose (60 percent), HIV diagnostic test (67 percent), general microscopy (68 percent), urine pregnancy test (67percent), and TB microscopy (57 percent).

Only 59 percent of rural facilities have the capacity to provide malaria diagnostic test, compared with 85 percentof urban facilities. Among facility types, malaria diagnostic tests are most available in hospitals (77 - 93 percent) thanhealth centers (67 percent).

Among all facilities the capacity of a health facility to conduct advanced level diagnostic tests is low (less than 7percent), except for stool microscopy and CSF/body fluid counts (63 and 67 percent respectively). However, the capacityto conduct advanced level diagnostic tests in hospitals differs among all types of hospital that ranges from 100 percent forserum electrolyte to 27 percent for syphilis serology. In general, urban facilities are more likely to have the capacity toconduct basic tests and advanced level of diagnostic tests than rural facilities.

Table 3.7.1 Laboratory diagnostic capacity, by facility type

Table 3.7.1 Laboratory diagnostic capacity

Among all facilities, the percentages with capacity to conduct basic and advanced laboratory diagnostic tests in the facility, by facility type, and urban/rural, EthiopiaSPA Plus-Census 2014

Facility type Urban/rural

Laboratory tests Referral Hospital General Hospital Primary Hospital Health Center Urban Rural Total

Basic testsHemoglobin 100 74 67 7 20 4 10Blood glucose 87 90 76 18 43 9 21Malaria diagnostic test 77 83 93 67 85 59 68Urine protein 97 94 98 60 83 50 61Urine glucose 97 94 96 59 82 49 60HIV diagnostic test 87 74 73 66 82 59 67DBS collection 23 19 22 10 24 4 11TB microscopy 81 79 73 56 76 47 57Syphilis rapid diagnostic test 81 61 51 18 33 13 20General microscopy 84 86 89 67 86 59 68Urine pregnancy test 100 94 96 65 87 56 67Liver or renal function test (ALT orCreatinine) 94 53 36 1 10 0 4

Advanced level diagnostic testsSerum electrolytes (chemistryanalyzer) 100 63 62 4 16 2 7Full blood count with differentials 100 63 62 4 16 2 7CD4 count 81 72 47 1 11 0 4Syphilis serology 32 31 27 4 13 1 5Gram stain 97 92 64 10 29 5 13Stool microscopy 84 82 89 62 80 54 63CSF/ body fluid counts 97 97 96 59 85 48 60

Number of facilities 31 71 44 3,314 1,177 2,283 3,460

Note: The basic test indicators presented in this table comprise the diagnostic capacity domain for assessing general service readiness within the health facilityassessment methodology proposed by WHO and USAID (WHO 2012).

Note: DBS = dried blood spot; CSF = cerebrospinal fluid; CT = computed tomography

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Table 3.7.2 Laboratory diagnostic capacity, by region

Table 3.7.2 Laboratory diagnostic capacity

Among all facilities, the percentages with capacity to conduct basic and advanced laboratory diagnostic tests in the facility by region, Ethiopia SPA Plus-Census 2014

Region

Laboratory tests Tigray Afar Amhara Oromia SomaliBenishangulGumuz SNNP Gambella Harari

AddisAbaba

D