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    >> ANNUAL REPORT, PROJECT 200452 & 200666, MARCH 31ST, 2021 ANNUAL REPORT 2020 STRENGTHENING THE HEALTH SYSTEM IN JIMMA AND BORANA ZONE (OROMIA REGION, ETHIOPIA) THROUGH PERFORMANCE BASED FINANCING (2019-2023) MARCH 31ST, 2021, ADDIS ABABA, ETHIOPIA POLITE DUBE BOBOH KAMANGIRA MAARTEN ORANJE INGE BARMENTLO CARMEN SCHAKEL GALGALO HALAKE DJARSO ABDULBARI ABDULKADIR KALEB MELAKU WOLDEMARIAM


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    TABLE OF CONTENTS LIST OF ABBREVIATIONS ................................................................................................3 EXECUTIVE SUMMARY .....................................................................................................4 PROJECT BACKGROUND .................................................................................................8 1. OUTCOME 1: IMPROVED HEALTH SERVICE DELIVERY ...........................................9 2. OUTCOME 2: IMPROVED GOVERNANCE OF HEALTH SERVICE DELIVERY .........61 3. OUTCOME 3: AN ENHANCED HEALTH INFORMATION SYSTEM............................66 CONCLUSIONS ................................................................................................................69 ANNEXES .........................................................................................................................71 Annex 1: Theory of Change (From: Original Proposal PBF Jimma and Borana Zone,) .................... 71 Annex 2: Logical Framework (From: Original Proposal PBF Jimma and Borana Zone) .................. 75 Annex 3: Quantity Indicators – Health Centres ..................................................................................... 82 Annex 4: Quantity Indicators – Hospital ................................................................................................ 83 Annex 5: Quality Checklist – Health Centre........................................................................................... 84 Annex 6: Quality Checklist – Hospital .................................................................................................... 85 Annex 7: Jimma Demographic Scope of PBF Programme (EFY 2013) ............................................... 86 Annex 8: Borana Demographic Scope of PBF Programme (EFY 2013) .............................................. 87 Annex 9: Overall Quality Scores per Health Centre in Jimma (Baseline and Q4 2020) .................... 88 Annex 10: Overall Quality Scores per Health Centre in Borana (Q3 2019 and Q4 2020) .................. 89 MARCH 2021 © CORDAID 2


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    LIST OF ABBREVIATIONS ANC Antenatal Care AMTSL Active Management of the Third Stage of Labor CAC Comprehensive (Post) Abortion Care CBHI Community Based Health Insurance DHIS2 District Health Information System 2 EDD Expected Date of Delivery EFY Ethiopian Fiscal Year EPI Expanded Program on Immunization EPSA Ethiopian Pharmaceuticals Supply Agency FMOH Federal Ministry of Health FGD Focus Group Discussion FP Family Planning HC Health Centre HEP Health Extension Package HF Health Facility Hgb Haemoglobin HMIS Health Management Information System HSEP Health Service Extension Programme HSTP Health Sector Transformation Plan IMNCI Integrated Management of Childhood Illness KPI Key Performance Indicator LMP Last Menstrual Period MNCH Maternal New-born and Child Health MRN Medical Record Number OPD Outpatients Department ORHB Oromia Regional Health Bureau PBF Performance Based Financing PHC Primary Health Care PHCU Primary Health Care Unit PIM Project Implementation Manual PMTCT Prevention of Mother to Child Transmission PNC Post Natal Care PPA Performance Purchasing Agency SOP Standard Operating Procedure TT Tetanus USAID United States Agency for International Development WHO Woreda Health Office ZHD Zonal Health Department ZOFED Zonal Office for Economic Development MARCH 2021 © CORDAID 3


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    EXECUTIVE SUMMARY This report outlines the progress made in the implementation of Performance Based Financing in Borana and Jimma Zone during the year 2020. The regular implementation of PBF in 68 and 25 health facilities in Jimma and Borana respectively was successful during the period under review, of which the results are clearly visible. Most notably, we are observing progress towards the objectives under Outcome Pathway 1, which directly target Improved Health Service Delivery. For Outcome Pathways 2 (Improved Governance of Health Service Delivery) and 3 (An Enhanced Health Information System), a lot of foundational work has been done, and more tangible results started becoming visible in the course of 2020. The last two months (November and December) were used as an Inception Phase for a new group of facilities, as the project is being expanded to the remaining 8 woreda of the Jimma Zone as of January 2021. Below we will briefly summarize the main achievements and challenges encountered during the year, as well as the milestones for each of the three Outcome Pathways, including the Jimma expansion inception phase. Looking at the intended outputs under Outcome 1, Improved Health Service Delivery, most progress on outputs 1A (the finalization of a Project Implementation Manual review) and 1B (the training of the health workforce in PBF), was realized during the last 4 months of the year and during the Jimma expansion Inception Phase. For all the other outputs (1C to 1F), the PBF implementation was in full force in both zones. All health facilities developed their first business plans and signed their first performance agreements and rigorous regular rounds of performance verifications continued. The monthly quantity verifications were conducted by Cordaid Jimma and Cordaid Borana as the PPA in all health facilities (except those designated as covid quarantine & isolation centres) and also quality verifications were conducted for all the quarters by local health authorities, assisted by Cordaid Jimma and Cordaid Borana except for hospitals in Q1 2020 due to Covid- 19 outbreak in Ethiopia. The community verifications (by the recruited CBOs) were also conducted every quarter in Jimma except in Q1 2020 due to Covid-19. While in Borana no community verifications took place in Q1 2020 due to recruitment of new CBOs, and feedback was shared with the health facilities. Based on the outcomes, all entities received their quarterly performance-based payment timely according to timelines outlined in the PIM. While data quality improvement is one of the first visible effects of PBF, the effect on the reported level of service utilization is more mixed. There has been significant improvement in the data accuracy in Jimma during the year under review as shown in Table 7 & figure 1 in the report. The percentage of cases being fully verified in Jimma has significantly increased across the woredas to an average of 83% compared to only 11.4% during the baseline (Table 7). Generally better accuracy levels are noted in Borana compared to Jimma (Tables 7 & 8) due to project experience time/duration factor though the rate of improvement in Jimma is noted to be faster than Borana. At the health centre level in Jimma, 83.4% of all declared cases could be fully verified during quarter 4, 2020, compared to 11.4% during the baseline, while Borana slightly improved from 89.8% in quarter 4 ,2019 to 92.1% during quarter 4 ,2020. The highest verifiable percentage was recorded in Botor Tolay and Dubluq Woradas in Jimma and Borana respectively while Omo Nada in Jimma and Guchi in Borana recorded the lowest percentages. The best performing indicators in terms of percentage of cases verified are Long term family planning methods and Adult Out-patient consultations in Jimma and Borana respectively. In Jimma, out of the 23 indicators, five indicators (21.7%) moved from red zone (<80% verified) to green zone (≥90% verified) while in Borana 12 out of 22 indicators (54.5%) either moved from red/amber zone or remained in green zone at the end of Q4 2020. For indicators falling in the red zone by end of Q4 2020, Jimma had 52.2% while Borana had 31.8%. At Hospital level, there was substantial improvement in data accuracy in terms of the percentage of declared cases verified in Jimma between baseline (7% verified) and Q4 2020 (70%) (Figure 12). However, Borana zone hospitals consistently maintained a high accuracy above 90% across the period under review except for the month of February where the proportion verified dropped to 72%. Significant improvements were seen in six indicators (37.5% of all indicators) which managed to have the proportion of verified cases being >90%. These indicators are skilled deliveries, long-term FP methods, VIAC Screening for Cervical Cancer, Caesarean sections, Blood transfusion and hypertensive patients treated. The main reasons for discrepancies included: poor documentation of cases as some of the information is not consistently filled in in all the columns of the registers, however the prevalence of such omissions has significantly reduced. Medical Record Number (MRN) and serial number is sometimes missed in some of the registers. Most of these causes were addressed throughout 2020 verifications through the intensive coaching of staff by the PPA staff. Combination of zero tolerance approach (rigorous and strict verifications) and enthusiasm among the staff of the health facilities has largely contributed also to the noted improvement as shown. Compared to the baseline it was noted that most health facilities started using the standardized DHIS 2 registers, properly filling each and every column based on the guideline and properly MARCH 2021 © CORDAID 4


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    reporting of the data in each register. Another contributing factor is that in most health facilities the performance monitoring teams are becoming more active and conduct regular verification of their data before sending the reports to their respective Woreda. With regards to quality at health centre level, there has already been improvement in indicators performance for both Borana and Jimma in the period under review. However, the improvement is more pronounced in Jimma when comparing the baseline study (19.5%) and Q4 2020 (52.3%) data, while in Borana there was more gradual improvement from Q3 2019 (50%) to Q4 2020 (58.3%). In fact, all service areas saw improvement in Jimma whereas in Borana, Administration, Finance and Planning and the Referrals indicators did not improve between Q3 2019 and Q4 2020. In Jimma, under 5 OPD was the highest performing indicator with 78.9% up from 40% while Outreach services was the least performing indicator with 19.5%. The other better performing quality indicators are logistics & supplies, ANC, referral, and EPI services while inpatient services, infection control, general appearance and emergency services are among the least performing quality indicators. In Borana, Nutrition services was the best performing indicator with 91.8% while Outreach services was the least performing indicator with 16.7%. The other better performing indicators were logistics & supplies, under 5 OPD, ANC, referral services while inpatient services, emergency services, HMIS and Supervision and Laboratory services were among the least performing indicators. In general, at Hospital level, there was significant improvement in the quality of services at hospital level both in Jimma and Borana (Figure 32). Jimma zone hospitals quality increased from 29% at baseline (Q3 2019) to a high of 74.4% in Q3 2020 before dropping down to 71.3% in the last quarter of 2020 while the Borana zone hospitals quality consistently increased from 64.3% to 91.1% in the same period. There were no quality verifications in Moyale Hospital since Q2 2020 as the facility was a covid-19 treatment centre which leaves Yabello as the only hospital in Borana with 91.1% and also as the best performing hospital in the entire PBF program (Figure 33). In Jimma zone, the best performing hospital was Omo Nada hospital with 87% while Setema hospital saw the biggest improvement of 47 percentage points between baseline and Q4 2020 (Figure 33). The least performing hospital in Jimma was Agaro hospital with 59%. Apart from being a newer hospital, the management of the Omo Nada and Yabello hospital in Jimma and Borana respectively are more committed and well organised: most staff in this hospital were showing ownership of the process of improving the quality of services. One best practice noted in Omo Nada and Yabello hospital is that the medical director ensures that the internal quantity and quality verifications are conducted well before the Cordaid verifiers and the ZHD arrives to perform the verifications. There has been a high level of motivation and commitment among health professionals to make this project a success, as well as a solid understanding of how PBF works. This shows tangible progress towards Medium Term Outcome 1.1 of the project: ‘health professionals function as a team, are motivated, pro-active and are respectful and caring towards their patients’. The average perceived quality by patients improved from 69.5% to 75.9% in Jimma and from 70.8% to 74.9% in Borana. As illustrated above by the improved accuracy and reliability of the data, progress is also being made towards Medium Term Outcome 1.5: ‘monthly HMIS data of the facilities is of good quality (reliable, accurate, timely and complete) and is used to take informed decisions.’ During this reporting period the project injected a total subsidies payment of ETB36,998,111 to 89 health facilities. Jimma and Borana health facilities earned ETB23,659,147 and ETB13,338.963 respectively. These total amounts do not include the subsidies paid for COVID-19 response indicators. On top of the above amounts the Fund Holder (Cordaid Ethiopia) made payments for COVID-19 response indicators for a total of ETB2,763.771 since occurrence of the pandemic in the country to the end of this reporting period. Comparing the subsidies paid in the last quarter of this reporting period against the same quarter of previous year, facilities earned more than double amount. Under Outcome 2, the project aims to contribute to Improved Governance of Health Service Delivery. All WHOs and ZHD were able to conduct the quality assessments successfully and objectively for all the quarters in 2020 except in hospitals during Q1 2020 due to Covid 19, though more technical support is still needed. The main gap which still needs to be addressed is the ability to conduct routine supportive supervision to the health facilities, for which they cite financial and transport related challenges. Generally, in both zones, the capacity of regulators at woreda and zonal level needs to be addressed as some have less years of experience and sometimes supervision teams lack people with certain technical expertise. Mobilisation of communities for CBHI still needs to improve in most woredas and also woredas still need to ensure timeliness of HMIS reports. Use of data for decision making still needs to be improved, for example by prioritizing underperforming health facilities using the quantity and quality assessment data which is shared with them routinely. In the midst of scarcity of resources, use of data is critical to inform the most efficient way to perform supportive supervision. MARCH 2021 © CORDAID 5


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    As a result, the indicator for regulars on action plans have been revised to include element of showing that the planned activities are informed by data. Due to expansion in Jimma total of 45 representatives of the regulators were trained on PBF during the period under review. Part of the efforts towards institutionalization of PBF was setting up of the regional PBF steering committee and also organising the study tours to Rwanda and Liberia for decision makers. The study tours however could not be conducted due to Covid-19 travel restriction during the period under review but there was rather a local tour to Jimma by FMoH and steering committee. The regional steering committee was set up and managed to hold two (2) meetings in 2020. The international study tours are therefore planned for 2021 on assumption that the restrictions will be eased. Activities under Outcome 3, which aims at An Enhanced Health Information System, were mostly work in progress by the end of the period under review. In 2019, BlueSquare was contracted by Cordaid to develop a PBF data system linked to the national DHIS2, as well as to develop the necessary tools for digital data collection (using smart phones and tablets) by the local verifiers and regulators (outputs 3A and 3B). The data system and all necessary tools were developed and implemented successfully in Jimma Zone in the course of 2020. Subsequently, a new agreement with BlueSquare was signed, to expand all these tools to the Borana Zone, and to additionally develop a data visualization platform (DataViz) for the PBF projects. The system was developed for Borana also during the period under review however due to many activities during the Q4 2020 the trainings where postponed to February 2021 and were conducted successfully for the PPA staff from Borana and new staff in Jimma. Regulators in Borana and from new woradas in Jimma were successfully trained in February 2021. The DataViz component is expected to be finalized by March or April 2021. Cordaid also continued with Proof of Impact to further develop and finalise the blockchain platform for the project, which will create additional financing potential for the Ethiopian health system through enhanced transparency. The progress has been satisfactory to date and on target with regard to timelines though they were delayed a bit by Covid,19. All the three health baskets were tested and sent live and the marketing strategy was finalised during the period under review. The solidity of the technical work by Proof of Impact was confirmed by an independent assessment, conducted in two phases by Blockchainlab Drenthe. The report was submitted to the Embassy in December 2020 Based on the three finalized health baskets, which are currently live on the Proof of Impact website (https://app.proofofimpact.com/fund), a marketing strategy was agreed upon: three separate marketing campaigns will take place in the first half of 2021, whereby different messages and images will be tested (through A/B testing), to see which ones are most successful. The outcomes of each of the three marketing campaigns will be thoroughly analyzed and feed into the design of the next campaign. The point-of-care verification of events through digital means has been postponed indefinitely. In close consultation with EKN, it was decided in late 2020 to adapt the contractual arrangements with Proof of Impact and focus only on the optimization and marketing of the now existing transaction platform To mitigate the impact of covid 19 on PBF program, we adopted some contextualized adaptations in line with the “RBF in Times of COVID-19: A Quick Reference Guide” developed by Cordaid Community of Experts on RBF. These adaptations/covid response were temporary and based on the availability of approved re-allocated budget and also the prevalence of the pandemic. The response was also in line with ORHB and the FMOH Covid-19 Management Handbook to ensure that it was relevant and aligned to the policies. This was done in close consultation with the Donor and also with ORHB which was making decision on-behalf of the steering committee which could not meet also due to the pandemic. The response focused on two categories namely input and output based. Under input-based, relevant PPE and medicines were procured in line with the ORHB response plan and distributed to regional and zonal levels for further distribution to health facilities. The output-based component focused on one (1) temporary quantity indicator and four (4) quality indicators which were temporarily added and were extracted from the FMoH Covid-19 Handbook. Each indicator had a price attached to it and was verified every quarter. This enabled the HFs to prioritize Covid-19 related activities and also earn additional income to compensate the reduced income due to decline in service utilization. Three (3) quantity indicators were also added at Worada Health Office level while two (2) where added at Zonal Health Department level. The Jimma Expansion Inception Phase. In October 2020, a PBF steering committee PIM review meeting was held, during which key proposed PIM changed were presented and approved. One of the approved changes was to expand the geographic coverage in Jimma from 13 woredas to all the 21 woredas effective January 2021. The last two months of the year (November and December) were used as an Inception Phase for the project. The inception phase activities included recruiting a team of eight (8) local verifiers in November 2020, who were trained in the PBF approach during the same month. During the same month, a further cascade of trainings to local stakeholders was organized: from each participating MARCH 2021 © CORDAID 6


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    entity (the eight woreda health offices, 57 health centres and 2 hospitals) two to three representatives were trained. In the direct aftermath of this event, the baseline study was conducted, to collect quantitative and qualitative information about baseline performance at all levels. These baseline visits were also used to sign the first performance agreements with facilities and local authorities, starting by the first of January 2021 (Tir EFY 2013), with which the official implementation of PBF was to begin. 57 CBOs were also recruited during the same period in all the eight new woradas. All in all, the project is very well on track. Despite major challenges posed by Covid 19 during the year under review, all essential implementation processes, including the contracting and verification, as well as the execution of the PBF payments, are taking place according to schedule. As a result, we may expect further improvement in health service delivery, governance and information systems in 2021. MARCH 2021 © CORDAID 7


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    PROJECT BACKGROUND In Ethiopia, Cordaid started to showcase PBF in the arid and pastoralist Borana Zone. After a participatory design process of six months, the project officially started on May 1st, 2015. Stakeholders involved in the design of the PBF project in Borana were among others the Oromia Regional Health Bureau (ORHB), the Borana Zonal Health Department (ZHD) and 4 Woreda (district) Health Offices. Phase I of the PBF project ended on the 30th of June 2018. Since the results were positive (which was also found in an external project evaluation done in November 2018) and contributed to an increase in both the utilisation and the quality of health care services, the Borana ZHD and Cordaid jointly designed a Phase II for the Borana zone: PBF was scaled up from 4 to 8 Borana woredas, from 9 to 25 health facilities and from a catchment population of 125,918 to a population of 488,556. Phase II started in July 2018. Both phases were supported by Cordaid funds. In March 2018, a PBF workshop, jointly organised by the FMoH and Cordaid, took place in Debre Zeit in which representatives of the FMoH, ORHB, the Borana Zonal Health Department, the EHIA, Cordaid, the Embassy of the Kingdom of the Netherlands and DFID participated. One of the subjects discussed was the need to scale up PBF to a non- pastoralist area. This to showcase that PBF also works in other settings than the arid and pastoralist Borana Zone. Introducing PBF in an area where people are largely living from subsistence farming might change the dynamics around PBF and would thus generate additional evidence about the effectiveness of PBF. Most participants advised that it would be preferred to focus on a non-pastoralist area in the Oromia Region. The idea was discussed with the Netherlands Embassy. The latter suggested it would be interesting to create synergy with income generating projects supported by them, such as the interventions of the Dutch company Moyee Coffee, who buys its coffee from farmers in the Limu Kossa woreda located in the Jimma Zone. After that the idea of scaling up PBF in the Jimma Zone was discussed with both the Oromia Region and the Jimma Zonal Health Department: both supported the project idea. In mid-2018 Cordaid was invited by the Netherlands Embassy to formulate a four (4) year proposal and budget for scaling up PBF to the Jimma Zone. Cordaid presented this proposal to the Embassy on the 10th of October 2018. Early April 2019 the Embassy approved the four (4) year project proposal using as starting date the 1st of April 2019. The overarching objective of scaling up PBF in the Jimma and Borana Zone is: “Improved availability and accessibility of good quality healthcare at primary and secondary level in the Jimma and Borana Zone (Oromia Region, Ethiopia), and a stronger health system at large, which supports the progressive realization of Universal Health Coverage (SDG 3.8) in this geographical area.” The three (inter-related) targeted Outcomes are: 1.Improved Health Service Delivery in the selected woredas of the Jimma Zone, reflected in: A. Increased utilization of good quality services B. Increased equity in access 2.Improved governance of health service delivery through: A. Increased capacity at the level of Woreda Health Offices and Zonal Health Department to perform their regulatory tasks and provide supportive supervision B. Institutionalisation of PBF in the Ethiopian health system 3.An enhanced health information system that supports: A. Data based decision making at Woreda, Zonal and Regional level B. Additional financing potential for the health system through enhanced transparency At the start of 2020, the Netherlands Embassy also took over the financial support of the PBF project in Borana Zone (for the period until 2022) and also approved the expansion in Jimma to cover all the woradas. This report describes the progress of both projects in 2020, against the Theory of Change and the Logical Framework. These were developed as part of the proposal and can be found in Annex 1 and 2 respectively. One chapter is dedicated to each of the three outcomes, in which results are reported per output. Naturally, during implementation deviations may occur from the original framework. Due to Covid 19 there was disruption of verification during first quarter of the year, however, to mitigate the continued impact we made some adaptions in the form of additional temporary Covid related indicators and also input component with provision of PPE and medicines to health facilities. MARCH 2021 © CORDAID 8


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    1. OUTCOME 1: IMPROVED HEALTH SERVICE DELIVERY The focus of this outcome is to ensure increased utilization of good quality services and increased equity in access. The utilisation and quality of services continued to improve during the year 2020. The health facilities under PBF are divided into 3 categories of remoteness based on the criteria outlined in the PIM. This chapter will describe in detail the general progress made and gives a comparison (of both quantity and quality performance) between the baseline/Q4 2019 and Q4 2020. There was noted significant improvement comparing baseline/Q3 ,2019 and Q4 2020 data1, due to rigorous verification process which include coaching and mentoring of staff in the health facilities. The percentage of cases being fully verified in Jimma has increased across the Woredas to an average of 83.4%, as it was only 11.4% during the baseline (Table 7). Generally better accuracy levels are noted in Borana compared to Jimma (Tables 7 & 8), due to project experience time/duration factor though the rate of improvement in Jimma is noted to be faster than Borana. While moderate improvement was also noted in Borana during the same period, improving from 89.8% in quarter 4 ,2019 to 92.1% during quarter 4 ,2020. In all contracted facilities the quality of services was also assessed during the baseline study as well as quarterly for the entire period under review. The Jimma baseline findings demonstrated that the quality of services was not satisfactory: at health centre level, facilities on average obtained only 19.25% of the total quality score (Figure 14). This improved, during Q4 2020, to 52.4%. Overall, there is a promising improvement in quality of services in Jimma Zone health centres across all the woredas as shown by the comparison in Figure 15 between the baseline and the Q4 2020 data. The highest performing woreda during the 4th quarter of 2020 was Setema with an average of 61% followed by Sigmo and Kersa, both with an average of 60% (Figure 15). The lowest performing woreda was Tiro Afeta with 39%. At the end of 2020, the highest performing health centre of all 64 facilities was Sigmo HC in Sigmo woreda with 81.1%, compared to 24.8% for Dacha Gibe HC in Tiro Afeta woreda. The least performing indicators are outreach, infection control, emergency services and inpatient services. The rigorous coaching from the PPA staff and some WHOs, investments by health facilities contributed the noted improvements during 2020. Also, the nature of the quantity indicators, which are directly linked to quality indicators, there has been remarkable improvement with regard to quality of services in most health facilities. Borana, on the other hand, did not see very significant increases in quality scores. Generally, the average scores fluctuated between 60% and 64% in the 2020 calendar year (Figure 14). Comparing the woredas in Borana, the best performing woreda was Dubuluk with 65% while the least performing woreda was Guchi with 45% in Q4 2020 (Figure 15). The highest performing health centre at the end of Q4 2020 was Dubuluk HC in Dubuluk woreda with 75.8% while Horbate HC in Elwaye woreda and Mado HC in Moyale woreda were the least performing health facilities with 40.2%. Fund Holder (Cordaid Ethiopia) made timely payments for all quarters to all contracted 87 health centers (64 in Jimma and 23 in Borana) and 6 hospitals (4 in Jimma and 2 in Borana). In Jimma a total of 20,705,835 ETB was paid for health centres (with an average of 323,529 ETB throughout the year) and a total amount of 2,953,312 ETB was paid to hospitals making the average subsidy hospitals earned through the year 738,328 ETB. Whereas in Borana a total amount of 11,490,908 ETB (499,605 ETB on Average) and 1,848,055 ETB (924,027 ETB on Average) was paid to health centers and hospitals, respectively. There has been improvements in key medical equipment and medicines in most health facilities due to the prioritization of these elements in the business plans. Sanitation and waste management infrastructure continued to be a priority in the business plans. To mitigate the impact of covid 19 on PBF program, we adopted some adaptations in line with the “RBF in Times of COVID- 19: A Quick Reference Guide” developed by Cordaid Community of Experts on RBF. These adaptations/covid response were temporary and based on the availability of approved re-allocated budget and also the prevalence of the pandemic. The response was also in line with ORHB response and also the FMOH Covid-19 Management Handbook to ensure that it was relevant and aligned to the policies. This was done in close consultation with the Donor and also with ORHB which was making decision on-behalf of the steering committee which could not meet also due to the pandemic. The response focused on two categories namely input and output based. Under input-based, relevant PPE and medicines were procured in line with the ORHB response plan and distributed to regional and zonal levels for further distribution to health facilities. The output-based component focused one (1) temporary quantity indicator and four (4) quality indicators which were temporarily added and were extracted from the FMoH Covid-19 Handbook. Each indicator had a price attached to it and were verified every quarter. This enabled the HFs to prioritize Covid-19 related activities and also earn additional income to compensate the reduced income due to decline in service utilization. 1 In the Ethiopian calendar, the first quarter of PBF implementation was the second quarter of the Ethiopian Fiscal Year 2012 (12 EFY). These are also the months for which DHIS2 data have been verified: Tikamet, Hidar and Tahesas 2012. However, in order to not create confusion with the project implementation schedule, which is in Gregorian calendar, throughout this report we will refer to this quarter as Q4 2019, a shift of only a few days. MARCH 2021 © CORDAID 9


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    Output 1A: An approved PBF PIM is in place / Inception Phase The activities planned for the inception phase where successfully implemented. A series of PIM review meetings were conducted in both Jimma and Borana to gather the views from HFs staff and regulators on the positives, negatives, challenges, and areas of improvement on the PBF project. All the findings were analysed and discussed by Cordaid technical team and also consolidated for discussion at the regional steering committee. A successful PIM review workshop was held in October 2020 with the steering committee and the proposed changes were approved. All relevant stakeholders participated in the review process. The stakeholders consisted of the FMoH, ORHB, EHIA, BoFEC, Jimma University, Jimma Zonal Health Department, Jimma and Borana zone woreda representatives, Hospital and health centre representatives and Cordaid. The suggestions from the stakeholders were incorporated into the draft PIM before it was finalised and shared with them. The main changes to the PIM were: - Integration of Borana and Jimma PIM - Increased scope (expansion in Jimma from 13 to 21 Woredas) - Costing of quantity indicators (Index price increased from 8ETB to 12 ETB in Jimma) - Costing of quality bonus for hospitals - Changes to the quality checklists - Addition of CAC indicator - Alignment of Borana and Jimma quantity indicators - Changes to WHO and ZHD indicators - Alignment of Borana Equity bonus criteria with Jimma one. - Alignment of business plans and contracts duration of six months In relation to the expansion in Jimma zone: recruitment of project staff was successfully done during the 3 months expansion inception period. This included eight (8) verification officers based in the Jimma zone and a new Coordinator for Borana. The core project team managed to provide intensive PBF training to the verification officers, who in their turn also participated in the rigorous training of the regulators and health facilities staff. Output 1B: There is a trained and regularly mentored Health workforce on PBF In Jimma representatives from health facilities, which were to be contracted under the expansion, were trained on PBF. The focus of the training was to have staff understand PBF as a Health Systems Strengthening approach, to understand the indicators (both quantity and quality), the associated processes (such as business planning, performance agreements & community verification by CBOs, and the way in which verification are conducted. Above all the training clearly highlighted how the PBF project fits withing the existing Ethiopia’s Health Sector Transformation Agenda (HSTP). In both Borana and Jimma during the last two quarters of 2020, 57 and 90 persons respectively from regulators and health facilities were trained on PBF, the participants were 52 males and 5 females in Borana while it was 81 males and 9 females in Jimma. The 1st training was a review meeting on the performance of PBF project. It was conducted with health facilities directors and heads of Woreda Health Office. The focus of the review meetings was to understand reasons for low performances, best practices, gather challenges and areas that needs to be revised in the PIM from each entity under PBF. Detailed discussions were conducted, and participants went through the different PBF tools and recommended some changes which we used as input for the revised PIM. The 2nd training was provided by Borana zonal BOFEC, and it was mainly focus on grant management in concepts of existing health care financing guideline. Basic concepts of PBF principles, Business planning and managements of 70% and 30% proportion was also discussed clearly. The participants listed in the below table were from Health Facilities both the Health Centres and the hospitals, district health office, Jimma zonal health department, Jimma Finance and Economic Cooperation office, and Jimma Health Insurance agency. Table1 and 2 below summarise the number of participants from each zone. MARCH 2021 © CORDAID 10


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    TABLE 1 » NUMBER OF HEALTH PROFESSIONALS TRAINED IN PBF (JANUARY-DECEMBER 2020), JIMMA N0 WOREDA # OF HEALTH FACILITIES TOTAL STAFF TRAINED MALE FEMALE 1 Agaro Town WorHO 2 7 71% 29% 2 Botor Tolay WorHO 4 9 56% 44% 3 Chora Botor WorHO 3 7 57% 43% 4 Dedo WorHO 8 3 67% 33% 5 Gera WorHO 6 3 100% 0% 6 Gomma WorHO 11 3 100% 0% 7 Gumay WorHO 3 7 86% 14% 8 Kersa WorHO 7 14 86% 14% 9 Limu Kosa WorHO 8 19 79% 21% 10 Limu Seka WorHO 6 3 100% 0% 11 Mana WorHO 7 3 100% 0% 12 Mencho WorHO 6 12 83% 17% 13 Nono Benja WorHO 4 3 100% 0% 14 Omo Beyem WorHO 4 8 100% 0% 15 Omo Nada WorHO 7 17 76% 24% 16 Seka Chekorsa WorHO 9 6 100% 0% 17 Setema WorHO 5 5 100% 0% 18 Shabe Sombo WorHO 5 11 100% 0% 19 Sigmo WorHO 5 11 73% 27% 20 Sokoru WorHO 6 3 100% 0% 21 Tiro Afeta WorHO 5 11 64% 36% 22 Jimma Zonal sectors 3 10 100% 0% Total 124 175 86.2% 13.8% TABLE 2 » NUMBER OF HEALTH PROFESSIONALS TRAINED IN PBF (JANUARY-DECEMBER 2020), BORANA # OF HEALTH TOTAL STAFF N0 WOREDA MALE FEMALE FACILITIES TRAINED 1 Dubluki WorHO 4 9 9 0 2 Elwaye WorHO 5 10 8 2 3 Gomole WorHO 1 3 3 0 4 Guchi WorHO 2 5 5 0 5 Moyale WorHO 5 13 12 1 6 Wachile WorHO 2 5 4 1 7 Yabelo Town WorHO 1 5 4 1 8 Yabelo WorHO 3 7 7 0 9 Zonal Health department - 6 6 0 Total 23 63 58 5 In the hospitals, 100% of participants were men. This is partly due to the fact that the number of female health workers in the hospital is limited. MARCH 2021 © CORDAID 11


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    Output 1C: Business planning and contracting. Through-out the year 2020 health facilities were developing quarterly business plans in accordance with the PIM and also as a prerequisite before signing bi-annual performance contracts with the Performance Purchasing Agency (PPA, Cordaid Jimma and Cordaid Borana office). 68 health facilities were still contracted to implement PBF in Jimma Zone. This includes 4 hospitals and 64 primary health centres. The PPA staff, in collaboration with the WHOs, managed to assist the HFs to develop their business plans for all the quarters in 2020. The quality of the business plans has improved, though WHOs still need to be proactive in this aspect. Generally, the HFs were able to identify their key priorities to focus on, including infrastructure rehabilitation, procurement of medical supplies and running costs. One of the basic management strengthening tools that helps greatly advance management in PBF is the development of a Business plan by the health facilities. It is developed by the management of the Health Facility with the full participation of facility staff members, with the support and facilitation from the District Health Office/Zonal Health Department (ZHD) and the performance purchasing agency. In Borana and Jimma PBF projects the business plan was prepared by health facilities staff by the direct support and coaching from PPA (verification officers) and District Health Office and ZHD. Since the inception of the project Health facilities are showing improvement on quality business plan preparation, especially in the areas of fully participating individual staff members, key problem identification and prioritization of the problems. But some health facilities need to exert their effort to realize this, and the main problem lies with the District Health Offices in supporting and helping facilities in problem identification and prioritization and timely submission of business plan and signing contractual agreement quarterly. TABLE 3.1 » NUMBER OF CONTRACTED AND IMPLEMENTING HOSPITALS AND HEALTH CENTRES PER WOREDA, JIMMA TOTAL # OF HEALTH # OF HEALTH TOTAL HEALTH WOREDA # OF HOSPITALS POPULATION POSTS CENTRES FACILITIES Agaro Town WorHO 41,961 2 2 1 5 Botor Tolay WorHO 65,387 16 4 0 20 Chora Botor WorHO 81,759 19 3 0 22 Gumay WorHO 86,917 14 3 0 17 Kersa WorHO 235,568 32 7 0 39 Limu Kosa WorHO 228,054 40 8 1 49 Mencho WorHO 183,129 19 6 0 25 Omo Beyem WorHO 139,306 16 4 0 20 Omo Nada WorHO 215,113 23 7 1 31 Setema WorHO 147,330 21 5 1 27 Shabe Sombo WorHO 159,988 20 5 0 25 Sigmo WorHO 132,057 20 5 0 25 Tiro Afeta WorHO 170,641 25 5 0 31 TOTAL 1,887,210 267 64 4 335 TABLE 3.2 » NUMBER OF NEWLY CONTRACTED HOSPITALS AND HEALTH CENTRES PER WOREDA, JIMMA # OF # OF HEALTH TOTAL HEALTH WOREDA TOTAL POPULATION HEALTH # OF HOSPITALS CENTRES FACILITIES POSTS Dedo WorHO 226,866 34 8 1 43 Gera WorHO 160,331 29 6 0 35 Gomma WorHO 304,750 36 11 0 47 Limu Seka WorHO 173,375 38 6 0 44 Mana WorHO 208,814 24 7 0 31 Nono Benja 84,407 19 4 0 23 WorHO MARCH 2021 © CORDAID 12


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    Seka Chekorsa 296,440 35 9 1 45 WorHO Sokoru WorHO 196,073 39 6 0 45 TOTAL 1,651,056 254 57 2 313 TABLE 4 » NUMBER OF CONTRACTED HOSPITALS AND HEALTH CENTRES PER WOREDA, BORANA TOTAL # OF HEALTH # OF HEALTH TOTAL HEALTH WOREDA # OF HOSPITALS POPULATION POSTS CENTRES FACILITIES Dubluki WorHO 32,203 0 4 0 4 Elwaye WorHO 50,599 0 5 0 5 Gomole WorHO 53,802 0 1 0 1 Guchi WorHO 23,451 0 2 0 2 Moyale WorHO 173,196 0 5 1 6 Wachile WorHO 30,605 0 2 0 2 Yabelo Town WorHO 29,668 0 1 1 2 Yabelo WorHO 47,857 0 3 0 3 TOTAL 441,381 0 23 2 25 The level of Health Facilities equity bonus (among others based on their remoteness) were determined using the equity- bonus criteria defined in the PIM during the year under review. The equity bonus continued to be applicable to the health centres only and not to the hospitals due to the criteria. Based on its geographic, socio-demographic and infrastructural context, a health centre might be entitled to an equity subsidy additional to their general PBF subsidy. This subsidy/bonus is measured by: the size of a HC’s catchment population, its distance from the nearest hospital, the state of the access roads, and the availability (or non-availability) of both public transportation and communication. The equity determination tool (included in the PIM) uses detailed criteria determine the eligibility for an equity bonus. Based on these criteria a health centre can fall into one of the following categories which was different in Jimma and Borana as outlined in the table: Jimma Borana 1 Total score of 0-3 Points on these Total yes score of 0-3 = obtained 0%equity score indicators: 0% equity bonus 2 Total score of 4-6 Points on these indicators: 10% equity bonus Total yes score of 4-5 = obtained 20%equity score 3 Total score of 7-10 Points on these Total yes score of 6 or more = obtained 40%equity score indicators: 20% equity bonus Determining equity scores for each health centre is a collaborative process between the PPA staff and Woreda representatives. During the year under review, see the table below, 26 out of 64 facilities fall in the 0% equity bonus category (so these HCs are not entitled to an equity bonus), while 27 HCs are in the 10% category and 11 HCs are in the 20% category. This last category of health centres is located in very hard to reach areas. In Agaro Woreda all the facilities are located in town, and well accessible so not eligible for any equity bonus. To the contrary, Botor Tolay Woreda has 3 out of 4 health centres working in difficult to reach areas. These HCs will therefore earn the maximum of a 20% equity bonus. Next to Botor Tolay woreda, there are two other woredas where all health centres earn an equity bonus: Mancho and Omo Beyyam. In Borana zone there were three categories on equity bonus provision based on the seven predefined criteria which were measured by YES or No category. Among 23 Health facilities which are candidates for equity bonus 10(44%) of them were not indicate for the bonus while 6 (26%), health facility obtained 40%, and 7 (30%) received 20%. MARCH 2021 © CORDAID 13


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    TABLE 5 » NUMBER OF HEALTH CENTRES PER EQUITY CATEGORY, JIMMA WOREDA CATEGORY 0% CATEGORY 10% CATEGORY 20% Agaro Town 2 0 0 Botor Tolay 0 1 3 Chora Botor 1 1 1 Gumay 1 2 0 Kersa 3 3 1 Limu Kossa 5 3 0 Mancho 0 5 1 Omo Beyyam 0 2 2 Omo Nada 4 2 1 Setema 2 3 0 Shabee 3 0 2 Sigmo 1 4 0 T/Afetaa 4 1 0 TOTAL 26 27 11 TABLE 6» NUMBER OF HEALTH CENTRES PER EQUITY CATEGORY, Borena WOREDA CATEGORY 0% CATEGORY 20% CATEGORY 40% Dubluki WorHO 1 3 0 Elwaye WorHO 1 2 2 Gomole WorHO 1 0 0 Guchi WorHO 0 1 1 Moyale WorHO 4 0 1 Wachile WorHO 0 0 2 Yabelo Town WorHO 1 0 0 Yabelo WorHO 2 1 0 TOTAL 10 7 6 Output 1D: Quantity and quality verifications Data in relation to the Quantity verifications TABLE 7.1 » TOTAL DECLARED AND VERIFIED CASES AND PERCENTAGE VERIFIED AT HC LEVEL PER WOREDA, JIMMA BASELINE BASELINE BASELINE % Q4 2020 Q4 2020 Q4 2020 % WOREDA DECLARED VERIFIED VERIFIED DECLARED VERIFIED VERIFIED Agaro Town WorHO 2,459 9 0.4% 13,100 13,189 100.7% Botor Tolay WorHO 4,674 655 14.0% 18,147 17,269 95.2% Gumay WorHO 4,974 313 6.3% 13,437 12,332 91.8% Mencho WorHO 11,480 1,251 10.9% 35,263 31,719 89.9% Omo Beyem WorHO 5,587 773 13.8% 18,958 17,021 89.8% MARCH 2021 © CORDAID 14


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    Tiro Afeta WorHO 9,380 1,549 16.5% 20,677 17,682 85.5% Limu Kosa WorHO 10,110 1,860 18.4% 30,091 25,557 84.9% Shabe Sombo WorHO 6,554 789 12.0% 25,883 21,931 84.7% Kersa WorHO 17,698 907 5.1% 58,214 48,759 83.8% Setema WorHO 5,224 462 8.8% 24,661 20,385 82.7% Chora Botor WorHO 3,446 583 16.9% 16,718 13,159 78.7% Sigmo WorHO 9,528 174 1.8% 20,665 15,894 76.9% Omo Nada WorHO 18,889 4,041 21.4% 44,080 30,401 69.0% TOTAL 110,003 13,366 12.2% 339,894 285,298 83.9% TABLE 7.2 » TOTAL DECLARED AND VERIFIED CASES AND PERCENTAGE VERIFIED AT HEALTH POST LEVEL PER WOREDA, JIMMA Q3 2020 Q3 2020 Q3 2020 % Q4 2020 Q4 2020 Q4 2020 % WOREDA DECLARED VERIFIED VERIFIED DECLARED VERIFIED VERIFIED Shabe Sombo WorHO 5,656 1,303 23.0% 5,681 2,669 47.0% Kersa WorHO 5,705 1,324 23.2% 7,040 2,781 39.5% Chora Botor WorHO 2,642 141 5.3% 3,048 1,172 38.5% Tiro Afeta WorHO 6,596 731 11.1% 6,343 1,702 26.8% Limu Kosa WorHO 2,668 190 7.1% 4,878 1,207 24.7% Omo Beyem WorHO 2,259 93 4.1% 2,809 657 23.4% Gumay WorHO 3,133 0 0.0% 3,030 585 19.3% Sigmo WorHO 4,216 4 0.1% 3,880 699 18.0% Setema WorHO 4,490 8 0.2% 5,251 791 15.1% Mencho WorHO 3,481 0 0.0% 4,111 133 3.2% Botor Tolay WorHO 1,381 29 2.1% 1,632 19 1.2% Agaro Town WorHO 0 0 133 0 0.0% Omo Nada WorHO 4,765 0 0.0% 5,417 0 0.0% TOTAL 46,992 3,823 8.1% 53,253 12,415 23.3% TABLE 8 » TOTAL DECLARED AND VERIFIED CASES AND PERCENTAGE VERIFIED AT HC LEVEL PER WOREDA, BORANA Q3 2019 Q3 2019 Q3 2019 % Q4 2020 Q4 2020 Q4 2020 % WOREDA DECLARED VERIFIED VERIFIED DECLARED VERIFIED VERIFIED Dubluki WorHO 7,686 7,466 97.1% 13,331 13,240 99.3% Yabelo WorHO 7,590 5,238 69.0% 11,145 10,494 94.2% Gomole WorHO 2,286 1,703 74.5% 4,197 3,925 93.5% Elwaye WorHO 15,235 13,664 89.7% 12,544 11,431 91.1% Wachile WorHO 4,498 3,308 73.5% 6,733 6,054 89.9% Moyale WorHO 9,677 8,402 86.8% 17,754 15,683 88.3% Guchi WorHO 2,797 2,687 96.1% 6,203 5,420 87.4% Yabelo Town WorHO 2,792 2,346 84.0% 0 0 TOTAL 52,561 44,814 85.3% 71,907 66,247 92.1% MARCH 2021 © CORDAID 15


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    There has been significant improvement in the data accuracy in Jimma during the year under review as shown in Tables 7.1 and 7.2 above and figure 1 below. The percentage of cases being fully verified in Jimma has increased across the Woredas to an average of 84%, as it was only 12.2% during the baseline (Table 7.1). Verification of health posts began in July 2020 and for the two quarters within the review period in which verifications at health post level took place, it can be noted that accuracy of data is also increasing across all woredas (Table 7.2). The highest performing health posts are in Shabe Sombo worada with 47% verifiable cases while the least are in Agaro and Omo Nada worada with 0%. Generally better accuracy levels in health facilities are noted in Borana compared to Jimma (Tables 7.1 & 8 above) due to project experience time/duration factor though the rate of improvement in Jimma is noted to be faster than Borana. While moderate improvement was also noted in Borana during the same period, improving from 85.3% in quarter 3 ,2019 to 92.1% during quarter 4 ,2020. During baseline quantity verifications in Jimma, a high discrepancy was found between declared and verified data. The highest verifiable percentage was recorded in Agaro Town and Dubluq Woradas in Jimma and Borana respectively while Omo Nada in Jimma and Guchi in Borana recorded the lowest percentages. Declared cases increased by 4% in Jimma during December 2020 compared to baseline (September 2019) while in Borana there has been 37% increase between Q3 2019 and Q4 2020. FIGURE 1 » TOTAL DECLARED & TOTAL VERIFIED CASES AT HC LEVEL PER WOREDA FOR 2020 During the period under review the main reasons for discrepancies included: poor documentation of cases as some of the information is not consistently filled in all the columns of the registers. However, the prevalence of such omissions has significantly reduced. Medical Record Number (MRN) and serial number is sometimes missed in some of the registers. Most of these causes were addressed throughout 2020 verifications via the intensive coaching of staff by the PPA staff. Combination of zero tolerance approach (rigorous and strict verifications) and enthusiasm among the staff of the health facilities has largely contributed also to the noted improvement as shown. Compared to the baseline it was noted that most health facilities started using the standardized DHIS 2 registers, properly filling each and every column based on the guideline and properly reporting of the data in each register. Another contributing factor is that in most health facilities the performance monitoring teams are becoming more active and conduct regular verification of their data before sending the reports to their respective Woreda. MARCH 2021 © CORDAID 16


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    FIGURE 2 » TREND IN PROPORTION OF SERVICES VERIFIED AT HC LEVEL (OCT 2019 – DEC 2020) While the accuracy of data is generally still high in Borana mainly due to program experience, the increase in data accuracy in Jimma since the first verifications in October 2019 has been tremendous (Figure 2). Data accuracy in Jimma has consistently increased to 86.2% of declared cases verified while Borana has seen a decrease in data accuracy in the most recent months, dropping from a high of 96.4% (August 2020) to a low of 87.7% (December 2020). FIGURE 3 » TOTAL DECLARED & VERIFIED CASES AT HC LEVEL PER INDICATOR 2020 (ONLY SHOWS INDICATORS > 3,000 VERIFIED CASES) Tables 9.1, 9.2 and 10 below and Figure 3 above present a comparison per indicator of declared and verified data during the baseline (September 2019) and Q4 2020 for Jimma, and Q3 2019 and Q4 2020 for Borana. Data quality improvement is one of the first visible effects that PBF has within a system, as is shown by the above presented data. Within a 15-month period, significant results can already be seen in Jimma (Table 9). As shown in Tables 9 and 10 below, the best performing indicators in terms of percentage of cases verified are Long term family planning methods and Adults Out-patient consultations in Jimma and Borana, respectively. In Jimma, out of the 23 indicators, seven indicators (30.4%) moved from red zone (<80% verified) to green zone (≥90% verified) while in Borana 12 out of 22 indicators (54.5%) either moved from red/amber zone or remained in green zone at the end of Q4 2020. For indicators falling in the red zone by end of Q4 2020, Jimma had 43.5% while Borana had 31.8%. The verifications at Health Post level stated in July 2020 after clearly refining the verification guideline for health posts. The overall verifiable cases improved from 8.1% in Q3 2020 to 23.3% in Q4 MARCH 2021 © CORDAID 17


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    2020. The better performance was in family planning (long term) with 28% of the cases meeting the verification criteria while the least was in Child fully immunised with 15.3%. Health posts were not documenting family planning and immunization services on the family folders before PBF but this is already improving following the first two quarters of verifications. TABLE 9.1 » TOTAL DECLARED AND VERIFIED CASES AND PERCENTAGE VERIFIED AT HC LEVEL PER INDICATOR, JIMMA ZONE BASELINE BASELINE BASELINE Q4 2020 Q4 2020 Q4 2020 % INDICATORS DECLARED VERIFIED % VERIFIED DECLARED VERIFIED VERIFIED Management of newborn HEI 7 0 0.0% 1 1 100.0% PNC1 3,091 0 0.0% 7,763 7,334 94.5% FP long term 2,805 25 0.9% 5,786 5,465 94.5% Skilled Deliveries 3,068 37 1.2% 7,761 7,321 94.3% Testing for HIV/AIDS 6,279 1,522 24.2% 51,562 48,464 94.0% Malaria Dx & Tx 808 125 15.5% 2,150 1,985 92.3% ANC1 (before 16wks) 1,256 1 0.1% 6,011 5,529 92.0% OPD Adults 51,881 10,234 19.7% 138,589 117,972 85.1% FP short term 4,943 52 1.1% 8,506 7,081 83.2% OPD Under 5 14,541 1,196 8.2% 42,029 34,549 82.2% Immunization (<1year) 1,527 13 0.9% 4,512 3,675 81.4% Diabetic Patients Tx 31 25 80.6% 191 155 81.2% Hypertensive Patients Tx 507 31 6.1% 3,327 2,662 80.0% Referrals 518 28 5.4% 3,375 2,689 79.7% STIs Treated 215 14 6.5% 621 483 77.8% Vitamin A suppl (<5 years) 4,911 0 0.0% 24,219 18,062 74.6% Hospital Bed days 127 13 10.2% 1,611 1,180 73.2% ANC4 3,094 37 1.2% 5,722 3,851 67.3% Growth Monitoring 9,879 0 0.0% 24,540 16,152 65.8% SAM Under 5 children 321 5 1.6% 1,252 575 45.9% TB Treated & Cured 63 6 9.5% 133 46 34.6% Microscopy TB Dx 130 2 1.5% 227 66 29.1% New on PMTCT Option B+ 1 0 0.0% 6 1 16.7% Total 110,003 13,366 12.2% 339,894 285,298 83.9% TABLE 9.2 » TOTAL DECLARED AND VERIFIED CASES AND PERCENTAGE VERIFIED AT HP LEVEL PER INDICATOR, JIMMA ZONE Q3 2020 Q3 2020 Q3 2020 % Q4 2020 Q4 2020 Q4 2020 % INDICATORS DECLARED VERIFIED VERIFIED DECLARED VERIFIED VERIFIED FP long term 6825 914 13.4% 9045 2535 28.0% FP short term 31664 2466 7.8% 33567 8247 24.6% Immunization (<1year) 8503 443 5.2% 10641 1633 15.3% Total 46,992 3,823 8.1% 53,253 12,415 23.3% TABLE 10 » TOTAL DECLARED AND VERIFIED CASES AND PERCENTAGE VERIFIED AT HC LEVEL PER INDICATOR, BORANA ZONE Q3 2019 Q3 2019 Q3 2019 % Q4 2020 Q4 2020 Q4 2020 % INDICATORS DECLARED VERIFIED VERIFIED DECLARED VERIFIED VERIFIED OPD Adults 20,061 20,062 100.0% 26,383 26,383 100.0% OPD Under 5 8,506 7,753 91.1% 8,731 8,670 99.3% MARCH 2021 © CORDAID 18


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    Minor Surgery 423 423 100.0% 577 572 99.1% Skilled Deliveries 1,007 917 91.1% 1,999 1,977 98.9% FP long term 722 679 94.0% 1,339 1,323 98.8% FP short term 1,093 817 74.7% 1,222 1,204 98.5% Testing for HIV/AIDS 9,282 9,006 97.0% 13,692 13,331 97.4% ANC1 (before 16wks) 502 328 65.3% 966 924 95.7% TB Treated & Cured 49 37 75.5% 41 39 95.1% Referred deliveries to hospital 122 128 104.9% 136 129 94.9% STIs Treated 571 634 111.0% 1,008 955 94.7% PNC1 1,125 884 78.6% 2,002 1,826 91.2% ANC4 723 344 47.6% 1,090 953 87.4% Diabetic Patients Tx 0 1 22 19 86.4% New on PMTCT Option B+ 4 3 75.0% 6 5 83.3% Immunization (<1year) 646 394 61.0% 929 692 74.5% Microscopy TB Dx 61 27 44.3% 44 31 70.5% Growth Monitoring 3,575 1,002 28.0% 5,340 3,624 67.9% Hypertensive Patients Tx 42 206 490.5% 467 305 65.3% Management of newborn HEI 3 2 66.7% 5 3 60.0% Vitamin A suppl (<5 years) 4,028 1,149 28.5% 5,849 3,251 55.6% SAM Under 5 children 16 18 112.5% 59 31 52.5% Total 62,767 56,388 89.8% 71,907 66,247 92.1% Trends in the service utilisation for various quantity indicators: We analysed the trends in the service utilization for the various indicators from the Jimma baseline period, (September 2019), to the last PBF month verified (December 2020) using both declared and verified data. There was a general increase in both declared and verified cases across all indicators in both Borana and Jimma zones between September 2019 and December 2019 before both declared and verified cases started to decrease until July 2020. The last two quarters of 2020 saw both declared and verified cases increase again in both Jimma and Borana zones across all indicators. While it is common in a PBF program to first see a drop in declared cases so that health centres do not miss out on subsidy earnings due to the 10% discrepancy rule, the trend noticed in 2020 for both Jimma and Borana is synonymous to seasonal trends in health seeking behaviours as well as the effects of the Covid-19 pandemic which was at its peak. Trends in Outpatient Consultations indicators: FIGURE 4 » TRENDS IN ADULT OPD SERVICE UTILISATION (SEPTEMBER 2019 – DECEMBER 2020) MARCH 2021 © CORDAID 19


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    FIGURE 5 » TRENDS IN UNDER 5 OPD SERVICE UTILISATION (SEPTEMBER 2019 – DECEMBER 2020) Outpatient service utilisation generally increased in Jimma whereas service utilisation levels remained fairly constant in Borana (Figure 4 and Figure 5). However, it can be noted for the period under review that service utilisation decreased significantly between January 2020 and July 2020 in Jimma for both adults (Figure 4) and children less than 5 years (Figure 5). In Borana, service utilisation decreased between January and April 2020 possibly due to Covid-19. In Jimma, declared cases of Under 5 OPD consultations increased from 14,541 in September 2019 to 14,899 in December 2020 representing a 2% increase while verified cases increased from 1,196 in September 2019 to 13,640 in December 2020 representing a 1,040% increase. The big percentage increase in verified cases is mostly due to an increase in the proportion of declared cases that were verified, which increased from 8% in September 2019 to 92% in December 2020. Declared cases of Adult OPD consultations decreased from 51,881 in September 2019 to 45,018 in December 2020 representing a 13% decrease while verified cases increased from 10,234 in September 2019 to 39,458 in December 2020 representing a 286% increase. The big percentage increase in verified cases is mostly due to an increase in the proportion of declared cases that were verified, which increased from 20% in September 2019 to 88% in December 2020. In Borana, declared cases of Under 5 OPD consultations increased from 2,970 in September 2019 to 3,734 in December 2020 representing a 26% increase while verified cases increased from 2,750 in September 2019 to 3,719 in December 2020 representing a 35% increase. The proportion of declared cases that were verified increased from 93% in September 2019 to 100% in December 2020. Both declared and verified cases of Adult OPD consultations increased from 7,879 in September 2019 to 8,641 in December 2020 representing a 10% increase. There was no change in the proportion of declared cases that were verified, which was already 100% both in September 2019 and December 2020. Trends in Family Planning (Short and Long Term Methods) indicators: FIGURE 6 » TRENDS IN FAMILY PLANNING (SHORT TERM) SERVICE UTILISATION (SEP 2019 – DEC 2020) MARCH 2021 © CORDAID 20


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    FIGURE 7 » TRENDS IN FAMILY PLANNING (LONG TERM) SERVICE UTILISATION (SEP 2019 – DEC 2020) For family planning indicators, declared cases decreased in the first four months of implementation in Jimma while verified cases increased, which is common in any PBF project (Figure 6 and Figure 7). From February 2020 until July, both short term and long-term family planning methods utilisation decreased due to both seasonal trends and Covid-19 pandemic (Figure 6 and Figure 7). It can be noted that after the peak in Covid-19 cases, service utilisation also started to increase before stabilising in the last quarter of 2020. However, the same cannot be said for Borana where there was steady rise in utilisation of family planning methods for the entire period under review. In Jimma, declared cases of Short-Term Family Planning methods decreased from 4,943 in September 2019 to 2,964 in December 2020 representing a 40% decrease while verified cases increased from 52 in September 2019 to 2,329 in December 2020 representing a 4,379% increase. The big percentage increase in verified cases is mostly due to an increase in the proportion of declared cases that were verified, which increased from 1% in September 2019 to 79% in December 2020. Declared cases of Long-Term Family Planning methods decreased from 2,805 in September 2019 to 1,904 in December 2020 representing a 32% decrease while verified cases increased from 25 in September 2019 to 1,836 in December 2020 representing a 7,244% increase. The big percentage increase in verified cases is mostly due to an increase in the proportion of declared cases that were verified, which increased from 1% in September 2019 to 96% in December 2020. In Borana, declared cases of Short-Term Family Planning methods increased from 357 in September 2019 to 421 in December 2020 representing an 18% increase while verified cases increased from 321 in September 2019 to 414 in December 2020 representing a 29% increase. The proportion of declared cases that were verified also increased from 90% in September 2019 to 98% in December 2020. Both the declared and verified cases of Long-Term Family Planning methods increased from 248 in September 2019 to 449 in December 2020 representing an 81% increase. There was no change in the proportion of declared cases that were verified, which was already 100% both in September 2019 and December 2020. MARCH 2021 © CORDAID 21


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    Trends in the Antenatal Care indicator: FIGURE 8 » TRENDS IN ANC1 (UNDER 16 WEEKS) SERVICE UTILISATION (SEPTEMBER 2019 – DECEMBER 2020) FIGURE 9 » TRENDS IN ANC4 SERVICE UTILISATION (SEPTEMBER 2019 – DECEMBER 2020) Figures 8 and 9 show the trends of both ANC visits before 16 weeks of gestation and women who completed 4 ANC visits respectively. Unlike the OPD indicators, there were no decreases in the verified cases in Jimma for both ANC indicators, except for the month of April 2020. However, declared cases dropped and started to increase again around May 2020 in Jimma. The decrease in declared cases in the first few months of implementation in Jimma is common to a new PBF project. Unlike in Jimma, the Borana ANC cases, both declared and verified, continued to increase steadily throughout the period under review. Trends observed in both Jimma and Borana indicate that there is no seasonality for ANC service utilisation. In Jimma, declared cases of the first ANC visit before 16 weeks increased from 1,256 in September 2019 to 1,977 in December 2020 representing a 57% increase while verified cases increased from 1 in September 2019 to 1,830 in December 2020. There is a significant increase in service utilisation of the first ANC visit before 16 weeks as shown by both declared MARCH 2021 © CORDAID 22


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    and verified cases recorded in December 2020 as they are more than the declared cases a year ago. However, the big percentage increase in verified cases is as a result of an increase in the proportion of declared cases that were verified, which increased from 0% in September 2019 to 93% in December 2020. As first ANC visits increased, the declared cases of four ANC visits completed decreased from 3,094 in September 2019 to 2,023 in December 2020 representing a 25% decrease while verified cases increased from 37 in September 2019 to 1,423 in December 2020 representing a 3,746% increase. The big percentage increase in verified cases is mostly due to an increase in the proportion of declared cases that were verified, which increased from 1% in September 2019 to 70% in December 2020. In Borana, declared cases of the first ANC visit before 16 weeks increased from 175 in September 2019 to 319 in December 2020 representing an 82% increase while verified cases increased from 144 in September 2019 to 308 in December 2020 representing a 114% increase. The proportion of declared cases that were verified also increased from 82% in September 2019 to 97% in December 2020. It can be noted that both declared and verified figures suggest that utilisation of ANC services by pregnant women before 16 weeks of gestation almost doubled in the year under review. For declared cases of four ANC visits completed, there was a 79% increase from 234 in September 2019 to 419 in December 2020 while verified cases also increased from 134 in September 2019 to 359 in December 2020 representing a 168% increase. The proportion of declared cases that were verified for four ANC visits completed also increased from 57% in September 2019 to 86% in December 2020. As seen in the first ANC visit before 16 weeks data, both declared and verified figures suggest that the utilisation of ANC services by pregnant women for four focused visits almost doubled in the year under review. Trends for the Skilled Deliveries indicator: FIGURE 10 » TRENDS IN SKILLED DELIVERIES SERVICE UTILISATION (SEPTEMBER 2019 – DECEMBER 2020) Skilled deliveries in Borana increased continuously for the entire period under review for both declared and verified cases (Figure 10). However, for Jimma zone, verified cases increased until January 2020 while declared cases decreased for the same period. Between February 2020 and August 2020, declared cases continued to decrease while verified cases also decreased before both started to increase. The decrease in service utilisation between February 2020 and August 2020 is not significant enough to attribute it to seasonality but most likely due to Covid-19 pandemic. In Jimma, declared cases of skilled deliveries decreased from 3,068 in September 2019 to 2,686 in December 2020 representing a 12% decrease while verified cases increased from 37 in September 2019 to 2,620 in December 2020. While the increase in verified cases can be attributed to improvement in data accuracy, which increased from 1% in September to 98% in December 2020, this could also be attributed to increase in service utilisation of skilled deliveries. In Borana, declared cases of skilled deliveries increased from 363 in September 2019 to 690 in December 2020 representing an 90% increase while verified cases increased from 328 in September 2019 to 677 in December 2020 representing a 106% increase. The proportion of declared cases that were verified also increased from 90% in September 2019 to 98% in December 2020. It can be noted that both declared and verified figures suggest that utilisation of skilled delivery services almost doubled in the year under review. MARCH 2021 © CORDAID 23


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    At hospital level, there was substantial improvement in data accuracy in terms of the percentage of declared cases verified in Jimma between baseline (7% verified) and Q4 2020 (70%) (Figure 12). However, Borana zone hospitals consistently maintained a high accuracy above 90% across the period under review, with the except of the month of February where the proportion verified dropped to 72%. Comparing the individual hospitals, Omo Nada in Jimma and Yabello in Borana had the best data accuracy (Figure 11). The narrow error margin recorded in Yabello and Omo Nada Hospital is due to a self-verification process initiated by the hospital management team. Prior to the monthly verification activity by the PPA’s Verification officers, the Yabello and Omo Nada Hospital Performance Monitoring Team conducted a self-verification using the same PBF checklist and this exercise was counter checked by the Hospital CEO. Agaro, Setema and Limu Genet Hospitals need to improve on the documentation of their cases as shown in Figure 11. FIGURE 11 » TOTAL DECLARED AND TOTAL VERIFIED CASES PER HOSPITAL FOR 2020 FIGURE 12 » TREND IN PROPORTION OF SERVICES VERIFIED PER ZONE (OCT 2019 – DEC 2020) Across the various hospital indicators, data accuracy improvement varied as shown in Table 11 and Figure 13 for Jimma Zone. Significant improvements were seen in six indicators (37.5% of all indicators) which managed to have the proportion of verified cases being >90%. These indicators are skilled deliveries, long-term FP methods, VIAC Screening for Cervical Cancer, Caesarean sections, Blood transfusion and hypertensive patients treated. While data quality improved for almost MARCH 2021 © CORDAID 24


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    all indicators, there were still three indicators for which no cases could be verified. These services, as shown in Table 11, typically do not have a high volume compared to some others which may have led hospitals to prioritize other indicators. OPD indicators remain high volume indicators that could still improve on data quality as these two indicators are among the least performing indicators in terms of data accuracy. For Borana, the data quality was consistently within 98% and 107% among all indicators (Table 12) except for Hypertensive patients treated and Diabetic patients treated which fell in the red zone. The least performing indicators are generally low volume. Best performing indicators for Borana in terms of accuracy and volume were Skilled deliveries, Major Surgeries and Caesarean Sections (Table 12). TABLE 11 » TOTAL DECLARED AND VERIFIED CASES AND PERCENTAGE VERIFIED AT HOSPITAL LEVEL PER INDICATOR, JIMMA ZONE BASELINE BASELINE BASELINE Q4 2020 Q4 2020 Q4 2020 % INDICATORS DECLARED VERIFIED % VERIFIED DECLARED VERIFIED VERIFIED Skilled Deliveries 526 0 0.00% 1513 1458 96.40% FP long term 65 0 0.00% 436 419 96.10% VIAC Screening 7 0 0.00% 23 22 95.70% Caesarian sections 72 20 27.80% 257 244 94.90% Blood transfusion 102 26 25.50% 212 200 94.30% Hypertensive Patients Tx 1209 358 29.60% 2282 2075 90.90% Diabetic Patients Tx 1021 179 17.50% 1871 1681 89.80% Existing patient on ART 9 0 0.00% 20 15 75.00% New on ART 8 0 0.00% 15 11 73.30% OPD Adults 17617 1133 6.40% 40584 27473 67.70% OPD Under 5 1900 0 0.00% 6052 3661 60.50% Microscopy TB Dx 8 2 25.00% 23 13 56.50% TB Treated & Cured 7 1 14.30% 10 3 30.00% Management of newborn HEI 3 0 0.00% 7 0 0.00% New on PMTCT Option B+ 3 0 0.00% 1 0 0.00% VIAC+ Treated 1 0 0.00% 0 0 Total 22,558 1,719 7.60% 53,306 37,275 69.90% TABLE 12 » TOTAL DECLARED AND VERIFIED CASES AND PERCENTAGE VERIFIED AT HOSPITAL LEVEL PER INDICATOR, BORANA ZONE BASELINE BASELINE BASELINE Q4 2020 Q4 2020 Q4 2020 % INDICATORS DECLARED VERIFIED % VERIFIED DECLARED VERIFIED VERIFIED Skilled Deliveries 774 702 90.7% 494 494 100.0% Major Surgery 244 204 83.6% 226 226 100.0% Caesarian sections 125 119 95.2% 105 105 100.0% Referred Deliveries received 87 82 94.3% 44 44 100.0% New on ART 32 35 109.4% 30 30 100.0% Microscopy TB Dx 24 24 100.0% 19 19 100.0% Existing patient on ART 32 29 90.6% 11 11 100.0% New on PMTCT Option B+ 13 13 100.0% 3 3 100.0% TB Treated & Cured 13 13 100.0% 2 2 100.0% MARCH 2021 © CORDAID 25


  • Page 26

    Blood transfusion 208 215 103.4% 100 101 101.0% FP long term 178 90 50.6% 155 153 98.7% OPD Adults 16,101 15,957 99.1% 8,666 8,512 98.2% OPD Under 5 4,953 2,936 59.3% 2,316 2,357 101.8% Management of newborn HEI 7 8 114.3% 13 14 107.7% Diabetic Patients Tx 11 32 290.9% 15 21 140.0% Hypertensive Patients Tx 17 67 394.1% 20 42 210.0% Total 22,819 20,526 90.0% 12,219 12,134 99.3% FIGURE 13 » TOTAL DECLARED & VERIFIED CASES AT HOSPITAL LEVEL PER INDICATOR 2020 (ONLY SHOWS INDICATORS > 500 VERIFIED CASES) Data in relation to the quality verifications: In all contracted facilities the quality of services was also assessed during the baseline study as well as quarterly for the entire period under review. The Jimma baseline findings demonstrated that the quality of services was not satisfactory: at health centre level, facilities on average obtained only 19.25% of the total quality score (Figure 14). This improved, during Q4 2020, to 52.4%. Following the rigorous coaching by the PPA staff, there was quite some improvement during Q4 2020 as shown by the following detailed information. Overall, there is a promising improvement in quality of services in Jimma Zone health centres across all the woredas as shown by the comparison in Figure 15 between the baseline and the Q4 2020 data. The highest performing woreda during the 4th quarter of 2020 was Setema with an average of 61% followed by Sigmo and Kersa, both with an average of 60% (Figure 15). The lowest performing woreda was Tiro Afeta with 39%. At the end of 2020, the highest performing health centre of all 64 facilities was Sigmo HC in Sigmo woreda with 81.1%, compared to 24.8% for Dacha Gibe HC in Tiro Afeta woreda. The low performing Health Centres generally lost scores in the area of infection control, emergency services and inpatient services. In general, these are some of the worst performing services across the woredas in the PBF program. Borana, on the other hand, did not see very significant increases in quality scores. Generally, the average scores fluctuated between 60% and 64% in the 2020 calendar year (Figure 14). Comparing the woredas in Borana, the best performing woreda was Dubuluq with 65% while the least performing woreda was Guchi with 45% in Q4 2020 (Figure 15). The highest performing health centre at the end of Q4 2020 was Dubuluq HC in Dubuluq woreda with 75.8% while Horbate HC in Elwaye woreda and Mado HC in Moyale woreda were the least performing health facilities with 40.2%. MARCH 2021 © CORDAID 26


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    FIGURE 14 » TRENDS IN AVERAGE QUALITY SCORE AT HC LEVEL (Q3 2019 – Q4 2020) FIGURE 15 » AVERAGE QUALITY SCORE AT PHCU LEVEL PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 80% 42% 41% 80% 10% 29% 40% 13% 0% 9% 60% 31% 23% 30% 29% 36%38% 24% 60% 8% 0% 4% 17% 2% 32% 40% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 As figure 16 clearly indicates, there has been improvement in indicator performance for both Borana and Jimma in the period under review. However, the improvement is more pronounced in Jimma when comparing the baseline study (19.5%) and Q4 2020 (52.3%) data for Jimma than in Borana for Q3 2019 (50%) and Q4 2020 (58.3%). In fact, all service areas saw improvement in Jimma whereas in Borana, Administration, Finance and Planning and the Referrals indicators did not improve between Q3 2019 and Q4 2020. In Jimma, under 5 OPD was the highest performing indicator with 78.9% up from 40% while Outreach services was the least performing indicator with 19.5%. The other better performing quality indicators are logistics & supplies, ANC, referral and EPI services while inpatient services, infection control, general appearance and emergency services are among the least performing quality indicators. In Borana, Nutrition services was the best performing indicator with 91.8% while Outreach services was the least performing indicator with 16.7%. The other better performing indicators were logistics & supplies, under 5 OPD, ANC, referral services while inpatient services, emergency services, HMIS and Supervision and Laboratory services were among the least performing indicators. The section below provides a detailed analysis for each category of the quality services, comparing between the baseline and Q4 2020. MARCH 2021 © CORDAID 27


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    FIGURE 16 » COMPARISON OF AVERAGE QUALITY SCORE PER SERVICE AREA AT HC LEVEL Quality in relation to the general appearance category: The General Appearance category includes outside appearance, courtyard, building appearance (both inside and outside), fire protection system, staff dress code, information and feedback, electricity, water and communication. The overall average quality score for the category General Appearance during the baseline study was 14.4% in Jimma and improved to 39.9% during Q4 2020 while it improved from 48.1% to 55.3% in Borana. The highest performing woreda for this category during Q4 2020 was Sigmo with 59% average, and Dubluqi and Gomole with 65% in Jimma and Borana respectively and the lowest were Chora Botor and Tiro Afeta districts in Jimma with 25% and Guchi with 44% in Borana. During Q4 2020 there was remarkable improvements across all woredas in Jimma with Sigmo district recording the highest percentage change of 49% while Chora Botor and Tiro Afeta districts recorded the lowest percentage change of 8%. In Borana there was much improvement across woradas, the highest percentage change of 35% was recorded by Gomole while there was no recorded change in Guchi district and Yabello town. The best performing HC in Jimma is Sigmo Health Centre in Sigmo Woreda (88.2%) while in Borana its Bokosa HC in Dubuluq Worada and Elwayee HC in Elwayee woreda with 88.2%. While there is some improvement, and differences among districts, gaps still exist in most health facilities with regards to this indicator: when we see appearance of buildings outside and inside like walls not painted, roof not intact, and there were broken windows and doors that cannot be locked, walls and floors not clean, with cracks, and roof with cobwebs, in most HFs fire extinguishers are available but not functional due to lack of service, and staff could not explain firefighting and evacuation procedure, grounding system not available, instructions on procedures to follow in case of emergency not available including evacuation system, and written evacuation diagram. Electricity is available for 24/7 in most facilities in delivery, OPD, inpatient room, and cold chain but back up system and at least 50 litters of fuel not available, and water reservoir available at health centres but there were not at least 2000 litres of water reserve. In some cases the health facilities do not have fence and it is rare for the grass to be cut and some litter, waste, dangerous objects are sometimes found in the courtyards of some health facilities MARCH 2021 © CORDAID 28


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    FIGURE 17 » HEALTH CENTRES QUALITY SCORE FOR GENERAL APPEARANCE AND SAFETY PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 0% 80% 49% 80% 4% 35% 60% 18% 32% 26% 34% 60% 8% 6% 9% 16% 34% 19%20% 8% 0% 40% 15% 8% 14% 29% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the administration and finance category: The overall average quality score for the category Administration and Finance during the baseline study was 11.6% in Jimma and improved to 42.3% during Q4 2020 while it improved from 56.5% to 58.2% in Borana. The highest performing woreda for this category during Q4 2020 was Kersa with 63% average and Dubluqi with 80% in Jimma and Borana, respectively, and the lowest were Agaro Town in Jimma with 15% and Gomole with 20% in Borana. During Q4 2020 there was remarkable improvements across all woredas in Jimma with Setema district recording the highest percentage change of 58% while Tiro Afeta recorded the lowest percentage change of 2%. In Borana there was not much improvement across woradas, the highest percentage change of 13% was recorded by Dubuluq while serious decline of 40% was recorded in Gomole. The best performing HC in Jimma is Sigmo Health Centre in Sigmo Woreda (100%) while in Borana the best are Bokosa HC in Dubuluq Worada, Elwayee HC in Elwayee woreda and Dikale HC in Yabelo Rural woreda with 100%. While there is some improvement, gaps still exist in most health facilities with regards to staff documents (including job descriptions) that could not be found. Most files only contain assignment letters. Furthermore, documents such as catchment maps do not have complete information, such as keys. There is no monitoring of KPIs, annual plans are not approved by the governing body and there are no separate quarterly and monthly plans. Additionally, there are no complete healthcare financing reports, invoices and revenue utilization are not approved by the governing body. Monthly staff and quarterly governing body meetings are not recorded. Health centre management committee meetings are also not regularly held and in some facilities were not conducted at all. The all-staff meeting was not conducted in most of the health facilities. This is one area where the WHOs need to build the capacity of HC staff, who are usually not trained as administrators or managers. Although there has been some improvement, there are still gaps in most of the districts which need to be fully addressed: Staff files / documents to assess job description were not available and if they exist the documents were not updated, Monitoring graphs for immunization, delivery, FP, ANC and 10 top diseases for both <5 and others including target population for services calculated correctly and available, but not updated timely, current annual, quarterly, and monthly plan and operational plan available, signed by HC management team but not approved by HC governing body, health care financing (HCF) reform guidelines for managing revenue not available and also if it is available a few finance officers were not showing compliance to the regulation, rules and procedures in the guideline, and the revenue collected report available signed by health centre head but not by WHO finance officer, retained revenue utilization plan of last 3 months not available and not approved by HC governing body, as all activities, procedures and issues lies on functionality of Health Centre Governing body, in most health centres the governing body not fully functional and active. MARCH 2021 © CORDAID 29


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    FIGURE 18 » HEALTH CENTRES QUALITY SCORE FOR ADMINISTRATION, FINANCIAL MANAGEMENT, HRM AND PLANNING PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 13% 0% -3% 80% 47% 80% -40% 58% 48% 8% 60% 33% 40% 60% 2% 5% 40% -5% 40% 10%13% 17% 20% 2% 20%25% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the HMIS and supervision category: The overall average quality score for this category during the baseline study was 12.7% in Jimma and improved to 50.9% during Q4 2020 while it improved from 41% to 47.4% in Borana. The highest performing woreda for this category during Q4 2020 was Sigmo with 89% average and Dubluk with 68% in Jimma and Borana respectively and the lowest were Agaro Town in Jimma with 29% and Wachile with 21% in Borana. During Q4 2020 there was remarkable improvements across all woredas in Jimma with Sigmo district recording the highest percentage change of 83% while Agaro, Botor Tolay and Omo Beyem districts recorded the lowest percentage change of 14%. In Borana there was some improvement across two (2) districts with decline recorded in Gomole and Yabello Town recorded no percentage change. The best performing HCs in Jimma are Bulbul Health Centre in Kersa Woreda, Boneya HC in Omo Nada woreda, Sentema HC in Setema woreda and Sigmo, Tora and Robe HCs in Sigmo woreda (100%) while in Borana the highest are Bokosa HC in Dubuluq Woreda Afura HC in Moyale woreda and Dikale HC in Yabelo Rural woreda with 100%. Although there has been some remarkable improvement, there are still some gaps which need to be fully addressed. Although monthly DHIS2 reports, most of which are on hard copy, were submitted on time to Woreda Health Offices, the woredas Health offices delay on entering data to the DHIS-2 data base some of which were due to poor internet connectivity and lack of internet connection, in most of the Health centres documents were not filed, stored in chronological order, clearly labelled and easily accessible, Health Centre Performance Monitoring team (PMT) available but not conducted meeting regularly on monthly bases that is still the discrepancy between declared and verified existed, and a few of the Health Centers were not actively using checklist for self-assessment on a quarterly basis. Most Health centres use updated registers which are consistent with the latest HMIS registers as they now order timely from ZHD and also able to re-print or photocopy using the subsidies. The other area that needs further improvement is quality assurance is not conducted by health centre staffs to review their performance regular and it is missed in majority of health facilities, this is mainly due to lack of integrated supportive supervision by Woreda health office experts. No guiding document for existence of integrated supportive supervision by Woreda health office like checklist and visitor books. MARCH 2021 © CORDAID 30


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    FIGURE 19 » HEALTH CENTRES QUALITY SCORE FOR HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS) AND SUPERVISION PER WOREDA JIMMA ZONE BORENA ZONE 100% 83% 100% 80% 18% -14% 0% 80% 47% 55% 66% 20% 60% 14% 60% 10% 29%43% 25% 33%14% 29% 17% 14% 40% 14% 40% -6% -7% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 f Quality in relation to the infection control and waste management category: The overall average quality score for the category during the baseline study was 4.4% in Jimma and improved to 37.6% during Q4 2020 while it improved from 55.6% to 60.1% in Borana. The highest performing woreda for this category during Q4 2020 was Omo Beyam with 57% average and Yabello rural with 80% in Jimma and Borana respectively and the lowest were Chora Botor and Gumay in Jimma with 20% and Moyale with 37% in Borana. During Q4 2020 there was some improvements across all woredas in Jimma though still very low with Omo Beyem district recording the highest percentage change of 52% while Shabe Sombo recorded the lowest percentage change of 19%. In Borana there was some improvement only in four (4) woradas, the highest percentage change of 36% was recorded by Yabello Rural while highest decline of 16% was recorded in Moyale. The best performing HC in Jimma is Kusaye Beru Health Centre in Kersa Woreda (87%) while in Borana its Seba HC in Elwaye Woreda with 91.3%. Compliance to IPC procedures still needs special attention for all health centres and Woreda Health Offices. The little improvement noted was due to improved awareness and compliance to IPC protocols though consistency is still needed. Facilities who had some improvements managed to attend to some infrastructural aspects like construction, renovation of incinerators and placenta pits. Most Health centres are yet to construct these to meet the expected standards. Waste management sites have been cleared up though they still need further renovations and proper fencing. Most Health facilities prioritised the purchase of IPC materials like three bin system especially in Borana where the investment have been for some time but most health centres especially in Jimma still need to invest more on IPC at the same time they are balancing with other critical investments. Generally, the cleanliness aspects still need to improve. We note that the environmental services really need to be strengthened throughout the zone as most health facilities do not have environmental health practitioners. The elements that need to be improved here includes availing two separate latrines for staffs and availing hand washing facilities with water in sustainable ways, the standards three bin system, especially at emergency and maternity side units, as the currently existing system is using plastic jars just to fulfil minimum standards rather than purchasing the standard ones to identify infectious and non-infectious medical wastes clearly and easily. MARCH 2021 © CORDAID 31


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    FIGURE 20 » HEALTH CENTRES QUALITY SCORE FOR INFECTION CONTROL & WASTE MANAGEMENT PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 80% 80% 12% -7% 0% 36% 45% 52% 13% 26% -7% 60% 47% 60% -16% 30%20% 36% 36% 42% 40% 17% 26% 19% 23% 40% 20% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the Out-Patient Department category: The overall average quality score for this category during the baseline study was 18.2% in Jimma and improved to 57.8% during Q4 2020 while it improved from 44.7% to 55% in Borana. The highest performing woreda for this category during Q4 2020 was Setema with 78% average and Elwaye with 78% in Jimma and Borana respectively and the lowest were Tiro Afeta in Jimma with 25% and Gomole with 27% in Borana. During Q4 2020 there was remarkable improvements across all woredas in Jimma with Setema district recording the highest percentage change of 58% while Tiro Afeta recorded the lowest percentage change of 9%. In Borana there was some improvement across four (4) Woreda, with decline recorded in Guchi worada. The highest percentage change of 36% was recorded by Wachile while highest decline of 14% was recorded in Guchi Gomole Woreda in Borana recorded no percentage change. The best performing HC in Jimma is Sigmo Health Centre in Sigmo Woreda (100%) while in Borana the highest is Dubuluk HC in Dubuluq Woreda and Horbate and Seba in Elwayee woreda with 100%. In 2019, there was a shortage of medical equipment, lack of guidelines and protocols required in the OPD consultation room and lack of privacy in the majority of the health centres, and these aspects have been improving throughout 2020. Health centres that recorded high improvement on this category managed to ensure that staff started using the guidelines and also managed to procure some medical equipment. The decline in Guchi Woreda in Borana is due to managerial issues at both woreda and health facility level which is being addressed by the Zonal Health Department. It is also the remotest woreda of the zone, and the staff of health facility are not motivated to bring change in their respective service unit/department which is merely due to the absence of transparency on PBF subsidy utilization and even staff’s incentives payments were not transparently done. The concerned health facilities are being investigated and necessary action will be taken. It was noted that almost all service providers are able to name the criteria for tuberculosis screening and the signs of dehydration for under five children. But there is no designated triaging area in most of the Health Centres in both zones which is mainly due to design of the health centres and some are improvising some available space around OPD area. MARCH 2021 © CORDAID 32


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    FIGURE 21 » HEALTH CENTRES QUALITY SCORE FOR GENERAL OUT-PATIENT DEPARTMENT (OPD) PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 58% 11% 80% 51% 53% 36% 33% 41% 41% 53% 80% 14% 36% 0% 60% 32% 33% 27% 60% -14% 29% 15% 40% 40% 0% 9% 9% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the Under 5 OPD category: This is one of the best performing indicators. The overall average quality score for this category during the baseline study was 34% in Jimma and improved to 78.9% during Q4 2020 while it improved from 67.9% to 72.7% in Borana. The highest performing woreda for this category during Q4 2020 was Sigmo with 93% average and Wachile with 94% in Jimma and Borana respectively and the lowest were Tiro Afeta in Jimma with 65% and Gomole, Guchi and Yabello rural with 63% in Borana. During Q4 2020 there was remarkable improvements across all woredas in Jimma with Limu Korsa district recording the highest percentage change of 53% while Botor Tolay recorded the lowest percentage change of 9%. In Borana there was some improvement across three (3) woradas with decline was recorded in Gomole and Guchi Woreda. The highest percentage change of 15% was recorded by Elwaye while highest decline of 25% was recorded in Gomole Woreda and Wachile recorded no percentage change. Jimma had 13 out of 64 HCs (20%) being the best performers with 100% while in Borana the highest performing HCs were Dubuluq HC in Dubuluq Worada, Tile Mado HC in Moyale woreda and Wachile HC in Wachile woreda with 100%. Facilities improved mainly due to improved adherence to the guidelines and having the ORT corners, curtains and an examination couch, Health facilities with improvement for this category tried to improve the availability of water, ORT corners and have IMNCI charts posted on the walls for reference. More equipment in some health facilities is still needed and health centres still continue to invest in them. Reasons for decline in Gomole woreda in Borana are for example: lack of IMNCI guidelines in the consultation room and some basic equipment in the consultation room are not available or not functioning (such as an otoscope). In most of health facilities in under five consultation room there are IMNCI booklet chart just on table, however they are expected also to have on wall in such easily understandable ways, and otoscope is lacking in most of health facilities. In other departments the main reason is that the health professional present during assessment indicate that the challenge was unavailability of this medical tool on the market. Though there was a shortage of medical equipment, lack of IMNCI guidelines and protocols required in the U-5 OPD consultation room and lack of privacy in many of the health centres during 2019 this have been improving throughout 2020. The reasons for decline at Tiro Afeta districts were mainly due to lack of IMNCI guidelines in the consultation room, ORT corner was not functional due to lack of ORT corner equipment’s, water and lack some basic equipment in the consultation room not available like otoscope. MARCH 2021 © CORDAID 33


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    FIGURE 22 » HEALTH CENTRES QUALITY SCORE FOR UNDER 5 OUT-PATIENT DEPARTMENT (OPD) PER WOREDA JIMMA ZONE BORENA ZONE 100% 38% 45% 50% 100% 0% 0% 53% 52% -25%-19% 9% 38% 46% 48% 53% 48% 6% 15% 80% 39% 48% 80% 13% 13% 60% 60% 40% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the emergency services category: The overall average quality score for this category during the baseline study was 3.4% in Jimma and improved to 42.2% during Q4 2020 while it improved from 34.1% to 40.2% in Borana. The highest performing woreda for this category during Q4 2020 was Setema with 78% average and Elwaye with 78% in Jimma and Borana respectively and the lowest were Tiro Afeta in Jimma with 16% and Gomole with 27% in Borana. During Q4 2020 there was remarkable improvements across all woredas in Jimma with Setema district recording the highest percentage change of 58% while Tiro Afeta recorded the lowest percentage change of 9%. In Borana there was some improvement across four (4) woradas with decline recorded in Guchi Woreda. The highest percentage change of 36% was recorded by Wachile while highest decline of 14% was recorded in Guchi, Gomole Woreda in Borana recorded no percentage change. The best performing HC in Jimma were Serbo and Kara Gora Health Centres in Kersa Woreda, Harewa Jimatee in Limu Kosa woreda and Sigmo HC in Sigmo woreda (100%) while in Borana the highest is Dubuluq HC in Dubuluq Worada and Afura HC in Moyale woreda with 100%. Although there has been investment and improvement in most health centres in Jimma, the emergency rooms are available but there is no adequate equipment, adequate medicines/supplies and no set-up of the emergency trays and all heath centres are encouraged to keep prioritizing this in their business plans. The main reason for low performance on emergency department is related to lack of equipment in this unit mostly share with OPD consultation not separately available at emergency rooms. This needs prioritising by the unit in their business plan. Since there is no standard shelf for storage of emergency drugs most of medical supplies are not found at this unit during assessment, EOPD tray is not functional in most cases. However currently in the recent quarterly business plan this department is prioritised for majority of health facilities to equip the room especially focusing on availing dressing sets, minor surgical sets, different emergency medicines, with tray and standard shelf in this unit to easy the management of medical equipment’s and medicines, as in most cases the health professional assigned to this unit complain of lost medicines and medical equipment. Furthermore, a full package of personal protective equipment is not available and Infection prevention policy and procedures not followed specially the three bin systems. The emergency room mainly serves as an injection room only. MARCH 2021 © CORDAID 34


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    FIGURE 23 » HEALTH CENTRES QUALITY SCORE FOR EMERGENCY SERVICES PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% -50% 80% 80% -8% 55% 56% 53% 53% 30% 60% 44% 42% 60% 33% 17% 31% 26% 13% 17% 40% 28% 30% 27% 40% -17% 20% 20% 0% 0% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the ANC category: The overall average quality score for this category during the baseline study was 40.2% in Jimma and improved to 66.2% during Q4 2020 while it improved from 67.4% to 71.6% in Borana. The highest performing woreda for this category during Q4 2020 was Agaro Town with 100% average and Dubluk with 81% in Jimma and Borana respectively and the lowest was Sigmo in Jimma with 55% and Gomole, Guchi and Wachile districts all with 63% in Borana. During Q4 2020 there was remarkable improvements across all woredas in Jimma compared to baseline though lot of improvement is still needed. Gumay district recorded the highest percentage change of 58% while Chora Botor showed no change recorded the lowest percentage change of 0%. In Borana also there was moderate improvement across three (3) woradas though there is huge decrement/decline in Gomole with 38% and no change in Guchi, Moyale, Wachile and Yabello town districts, while Dubluk recorded the highest percentage change of 19%. The best performing HCs in Jimma were Wolda and Agaro Health Centres in Agaro Woreda, Chora Ancebi HC in Botor Tolay Woreda, Toba HC in Gumay Woreda, Serbo and Kara Gora HCs in Kersa Woreda, Alee in Omo Nada Woreda, Sentema Kecha in Setema Woreda and Dimtu in Tiro Afeta Woreda (all with 100%) while in Borana the highest were Gobso and Dubuluq HCs in Dubuluq Woreda, Elwaye HC in Elwaye Woreda, Tuqa and Afura HCs in Moyale Woreda and Didd Yabello in Yabello Town, all with 100%. In most of the Health Centres/districts there was good progress for this indicator compared to 2019, the main reason is that most of the ANC service is provided by Midwives trained on the ANC protocols and procedures, availability of protocols and providers being able to name danger signs during a pregnancy, availability of Obstetric History card that is used and filled by providers correctly. Though there is still need to improve on ANC client’s vitals, laboratory tests assessments are not done due to lack of some reagents for tests, functional laboratory unit not available and lack of lab technicians in most centres. As a result, some health facilities do not offer these service MARCH 2021 © CORDAID 35


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    FIGURE 24 » HEALTH CENTRES QUALITY SCORE FOR ANTENATAL CARE (ANC) PER WOREDA JIMMA ZONE BORENA ZONE 50% -38% 0% 100% 100% 19% 0% 13% 80% 19% 58% 9% 15% 8% 80% 10% 0% 19% 47% 41% 40% 0% 0% 60% 35% 20% 60% 40% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the maternity services category: The overall average quality score for this category during the baseline study was 13.1% in Jimma and improved to 48.8% during Q4 2020 while it improved from 46.2% to 59.8% in Borana. The highest performing woreda for this category during Q4 2020 was Chora Botor with 74% average and Yabello rural with 68% in Jimma and Borana respectively and the lowest were Shabe Sombo and Tiro Afeta in Jimma both with 29% and Guchi with 39% in Borana. During Q4 2020 there was remarkable improvements across all woredas in Jimma compared to baseline though lot of improvement is still needed. Kersa district recorded the highest percentage change of 49% while Tiro Afeta recorded the lowest percentage change of 16%. In Borana also there was moderate improvement across seven (7) woredas though slight and lowest change of 1% recorded in Yabello Rural Woreda while Gomole recorded the highest percentage change of 26%. The best performing HC in Jimma is Kara Gora Health Centre in Kersa Woreda (100%) while in Borana the highest is Chari Rufayi HC in Elwayee Worada with 85.2%. In almost all Health Centers there is separate maternity waiting area that is protected against sun and rain, IEC materials posted on the wall though not adequate, most of maternal health service provider could name danger signs during and after pregnancy, and newborn danger signs, these mostly attributed by the availabilities and usage of guideline. But in most health centers delivery room, there was no running water with soap, two delivery beds existed but most of which rusted, broken, mattress and mattress cover torn. Almost all of health facilities do not have separate prenatal care room due to design of the maternity side blocks which is national standard and uniform in all health centres. In most Health Center instruments and equipment such as delivery sets and episiotomy set not organized and prepared well even in a few facilities the instruments were used without proper decontamination and sterilization: lack of speculum of different sizes, no refrigerator for Oxytocin in delivery ward, and in most maternity ward emergency tray was not equipped with the essential drugs, supply, and equipment. Thus, Health facilities both in Borana and Jimma zones need to prioritize and plan on the business plan and invest on it. This means that the Active Management of the Third Stage of Labour (AMTSL) is not managed properly. Also, the quality for new-born care is poor as the ‘new-born care corners’ are not fully equipped in most health centres. MARCH 2021 © CORDAID 36


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    FIGURE 25 » HEALTH CENTRES QUALITY SCORE FOR MATERNITY SERVICES PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 42% 80% 80% 12% 21% 13% 1% 60% 44%19% 49% 47% 46% 41% 46% 15% 26% 40% 20% 39% 60% 0% 40% 23% 16% 6% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the EPI and growth monitoring category This is one of the better performing indicators with 77% (10/13 woredas) and all woredas scoring averages above 60% in Jimma and Borana respectively. The overall average quality score for this category during the baseline study was 29.9% in Jimma and improved to 67.3% during Q4 2020 while it improved from 60.7% to 69.1% in Borana. The highest performing woreda for this category during Q4 2020 was Agaro town with 83% average and Elwaye with 78% in Jimma and Borana respectively and the lowest were Tiro Afeta in Jimma both with 50%% and Wachile with 60% in Borana. During Q4 2020, all woredas in Jimma improved significantly compared to baseline though more improvement is still needed. Agaro town district recorded the highest percentage change of 60% while Tiro Afeta recorded the lowest percentage change of 15%. In Borana also there was moderate improvement across four (4) woredas and some decline remaining woredas. Lowest positive change of 8% was recorded by both Moyale and Wachile and highest decline (-13%) was recorded in both Gomole and Yabello Rural Woreda with Guchi recording -2% decline. Elwaye recorded the highest percentage change of 22%. The best performing HC in Jimma were Sedu Health Centre in Setema Woreda and Dakano Elke in Omo Beyam Woreda (100%) while in Borana the highest were Chari Rufayi HC in Elwayee Worada and Moyale HC in Moyale Woreda with 91.7%. There is some improvement in Borana on this category in some health centres because most of the improvements do not require any additional resources. This is a unit that need strict technical support from a program person within the government system, even if it does not need huge investments, health facilities are unable to avail wastage monitoring charts, vaccine order forms, adverse effect investigation and report forms. Also, most of the service providers do not know how to calculate their monthly and quarterly average consumption for EPI accessory and for vaccine. The district health office technical team should support this activity closely. In Jimma, in almost all Health Centres there is a separate room designated to Immunization services, static EPI schedule available in all health facilities, Availability of EPI accessories, formats like: Vaccine carriers, Cold box, scissors and Vaccine order forms, vaccine stock cards, Adverse Effect Investigation Forms, Case investigation forms for EPI targeted diseases, Vaccine wastage monitoring forms and EPI card, EPI modules, case definition for vaccine preventable diseases were displayed in EPI unit were the most remarkable achievement in most HFs. In almost all HFs there is a functional fridge, that is kept clean and properly managed, and monitored twice a day. But Immunizations services are not provided on daily basis the main reason for this was to avoid vaccine wastage and vaccination were conducted mostly at the Health Posts and community level, EPI monitoring chart is consistent/tally with report for penta1, penta3, measles and fully vaccinated child because in most Health Centres the monitoring chart was used as PHCU not as Health Center though they were coached on this issue most HCs were not trying to change this existing pattern. Lack of monitoring Monthly Average Consumption (MAC) of vaccine and maintaining stock balance was observed in most HFs. Lack of following Multi-Dose Policy was observed. Also, most health centers lack a plan of action during power interruption to maintain the cold chain and prevent the vaccine from damage. MARCH 2021 © CORDAID 37


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    FIGURE 26 » HEALTH CENTRES QUALITY SCORE FOR EXPANDED PROGRAMME ON IMMUNIZATION (EPI) AND GROWTH MONITORING (GM) PER WOREDA JIMMA ZONE BORENA ZONE 100% 60% 100% -13% 34% 35% 47% 50% 22% -13% 80% 33% 42%43% 39% 42% 32% 80% 20% -2% 8% 60% 19% 8% 0% 15% 60% 40% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the nutrition services category: This is one of the better performing indicators with 77% (10/13 woredas) and all woredas scoring averages above 60% in Jimma and Borana respectively. The overall average quality score for this category during the baseline study was 32.5% in Jimma and improved to 57.5% during Q4 2020 while it improved from 82.6% to 91.8% in Borana. The highest performing woreda for this category during Q4 2020 was Sigmo with 68% average while Guchi and Wachile recorded 100% % in Jimma and Borana respectively. The lowest were Gumey in Jimma both with 47% and Gomole with 80% in Borana. During Q4 2020, all woredas in Jimma slightly improved except Kersa Woreda (-6%) with decline compared to baseline and more improvement is still needed. Agaro town district recorded the highest percentage change of 60% while Shambe Sombo recorded the lowest percentage change of only 4%. In Borana also there was good improvement across four (4) woradas and some decline remaining woredas. Lowest positive change of 4% was recorded by Elwaye and decline (-20%) was recorded in both Gomole. Guchi recorded the highest percentage change of 50%. The best performing HC in Jimma were Sentema Kecha and Gesecha Health Centres in Setema Woreda and Sigmo Health Center in Sigmo Woreda (100%) while in Borana 13 out of the 23 HCs (57%) scored a 100%. In most Health facilities of Jimma zone there were nutrition/malnutrition management guidelines, with the trained professionals that adhere to guideline while admitting, treating, and discharging the patients that is why health workers answer most of the knowledge assessment parts of this indicator easily. But there is still a need to improve having separate unit for stabilization center (SC) and ensuring the availability of functional equipment like blanket, matrasses and weighing scales in the stabilisation centre and not equipped according to the national standard. Moreover, health workers do not stick to the discharge criteria or record the trend in few facilities. The lower score at Gumay district was mainly attributed to a lack of separate SCs at Health Centres. In Borana nutrition service is one of the high scoring service unit in all health facilities, the unit is separately designated, equipped with all medical equipment, the management is strictly following the guideline. The lower performance at Surupa health centre in Gomole worada is because there is no health professional assigned for this service due to shortage of manpower and this activity is managed as additional duties by all health professionals. MARCH 2021 © CORDAID 38


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    FIGURE 27 » HEALTH CENTRES QUALITY SCORE FOR NUTRITION SERVICES PER WOREDA JIMMA ZONE BORENA ZONE -20% 50% 8% 10% 7% 100% 100% 0% 4% 80% 56%4% 24% 80% 60% 60% 45% 33% -6% 55% 20% 10% 11% 0% 0% 47% 60% 40% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the inpatient services category: This is one of the worst performing indicators in both zones all woradas scoring averages far below 50% except Gomole in Borana which scored 50% (This woreda has 1 facility). The overall average quality score for this category during the baseline study was 1.6% in Jimma and improved to 21.4% during Q4 2020 while it improved from 2.2% to 18.2% in Borana. The highest performing woreda for this category during Q4 2020 was Omo Nada with 48% average and Gomole with 50% in Jimma and Borana respectively and the lowest were Agaro Town in Jimma both with 0% and Elwaye. Guchi and Yabelo rural all scoring 0% in Borana. During Q4 2020, only five (5) woredas and four (4) woredas in Jimma and Borana improved slightly compared to baseline. Omo Nada district recorded the highest percentage change of 43% while Limu Korsa recorded the lowest percentage change of only 4%. In Borana the lowest change of 25% was recorded by both Dubluq and Wachile and highest decline was recorded in both Gomole with 50%. The better performing HCs in Jimma were Ale and Nada HCs in Omo Nada Woreda and Gatira HC in Setema Woreda (100%) while in Borana the highest were Gobso and Dokole HCs in Dubuluq Worada, Elwayee HC in Elwayee Woreda, Surupa HC in Gomole, Tile Mado, Afura and Tuqa HCs in Moyale and Wachile HC in Wachile Woreda with 50%. In almost all Health Centres in both zones, this is one of the lowest performing indicators mainly due to lack of inpatient room, no separate room for male and female being available and all health centres are using inappropriate old registers and therefore information on registers and patient cards do not match. However, some health facilities have already improved on this area. The revised PIM has taken into consideration this infrastructural design issue which is beyond the health facility. FIGURE 28 » HEALTH CENTRES QUALITY SCORE FOR INPATIENT SERVICES PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 80% 80% 60% 33% 43% 60% 50% 33% 33% 27% 40% 20% 40% 25% 30% 25% 20% 11%11% 13% 0% 4% 6% 7% 20% 0% 0% 0% 0% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 MARCH 2021 © CORDAID 39


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    Quality in relation to the referral services category: Referral services indicator is one of the fairly performing indicators in Jimma where all worada recorded remarkable improvement but in Borana some woredas declined in performance. The overall average quality score for this category during the baseline study was 23.4% in Jimma and improved to 64.6% during Q4 2020 while it did not change from 69.7% in Borana. The highest and modal average score was 67% in eight (8) woradas for this category during Q4 2020 and Moyale with 80% in Jimma and Borana respectively and the lowest were Chora Botor in Jimma both with 50% and 67% modal average in four (4) woradas in Borana. Mencho district recorded the highest percentage change of 58% while Chora Botor recorded the lowest percentage change of 22%. In Borana lowest positive change was recorded by both Dubluq with 8% change and highest decline was recorded in both Elwaye and Wachile with -17%. No change was recorded in Gomole, Guchi and Yabello rural. Fifty-eight out of the 64 facilities (91%) in Jimma had the highest score of 66.7% while in Borana the highest were Elwayee HC in Elwayee Woreda and Afura and Tile Mado HCs in Moyale Woreda with 100%. In most Health centres that performed well on this category, a mobile phone number to call for ambulance is posted on the wall, clearly visible and readable, standard forms for referral are available and enough, referral register is available and properly filled. But most Health Centres failed to collect or receive filled referral notes feedback from hospital and some health centres do not complete the forms properly. Since the Health Centres have all along been penalised for not receiving feedback from the Hospital, this has been revised in the revised PIM so that the penalty is on hospitals while HCs are held responsible for ensuring that the referral forms are filled in properly and completely with adequate patient details, diagnosis, reason for referral and pre-referral management. FIGURE 29 » HEALTH CENTRES QUALITY SCORE FOR REFERRAL SERVICES PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% -17% 23% -17% -11% 80% 42% 42% 80% 8% 33% 48% 23% 58%33% 40% 53% 57%30% 47% 0% 0% 0% 60% 22% 60% 40% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the outreach and health post supervision category: This indicator is one of the poor performing indicators in both zones. The overall average quality score for this category during the baseline study was 3.9% in Jimma and improved to 19.5% during Q4 2020 while it improved from 8.7% to 16.7% in Borana. The highest average score was 56% in Botor Tolay worada for this category during Q4 2020 and Moyale with 33% in Jimma and Borana respectively and the lowest were Mencho in Jimma both with 4% and 0% modal average in four (4) woradas in Borana. Botor Tolay district recorded the highest percentage change of 50% while Mencho recorded the lowest percentage change of 0%. Gumey and Tiro Afata in Jimma recorded decline of 8 % and 5% respectively. In Borana lowest positive change was recorded by both Dubluq with 17% change and highest decline was recorded in both Elwaye and Gomole with -33%. No change was recorded in Elwaye, Wachile, Guchi and Yabello rural. The better performing HC in Jimma were Boro, Chora Anchebi and Wayu HCs in Botor Tolay Woreda (75%) while in Borana the highest were Bokosa HC in Dubuluq Woreda and Afura HC in Moyale Woreda with 66.7%. This indicator is one of the least performing indicators in almost all districts of both Zones, in most health facilities there were no outreach health promotion plans, health education schedules and lack of regular supportive supervision of Health posts and kebeles by Health Centre staffs. Health education sessions are not conducted regularly in some of the assessed health centres. Facilities which showed improvement have started conducting supportive supervision of health posts and MARCH 2021 © CORDAID 40


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    health education activities in the health centres. The main cited challenge is shortage of staff and transport. Some health centres have since procured motorbikes to address transport challenge. The health supervision reports are also not usually written. However, the tool previous scoring mechanism was expecting the health centres to visit 100% of the health posts every week for them to earn all the points and this has since been adjusted to recognise the effort put in proportion of some health posts are visited. FIGURE 30 » HEALTH CENTRES QUALITY SCORE FOR OUTREACH AND HEALTH POST SUPERVISION PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 80% 80% 50% 60% 60% 40% 8% 29% 29% 25% -33% 27% 40% 17% 13% -8% 16% 10%15% -5% 20% 6% 20% 0% 0% 0% 0% 0% 0% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to the laboratory services category: Laboratory services indicator was one of the fairly performing indicators in Jimma following some fair improvement and nearly the same picture in Borana except Gomole with above 80%. The overall average quality score for this category during the baseline study was 24.3% in Jimma and improved to 51.7% during Q4 2020 while it improved from 33.2% to 50% in Borana. The highest average score was 75% for this category during Q4 2020 and Gomole with 86% in Jimma and Borana respectively and the lowest were Mencho in Jimma both with 19% and Guchi worada with 25% in Borana. Omo Beyem district recorded the highest percentage change of 52% while Tiro Afata recorded the lowest percentage change of 10%. In Borana highest change is 33% in Elwaye lowest positive change was recorded by both Moyale with 13% change and decline was recorded in both Dubluq with -2%. The better performing HCs in Jimma were Serbo HC in Kersa woreda, Babu HC in Limu Kosa woreda, Dakano Elke in Omo Beyem woreda, Nada, Ale and Asendabo HCs in Omo Nada and Sedu and Gatira in Setema woreda (85.7%) while in Borana the highest were Dubuluq in Dubuluq woreda, Adegalchat and Elwaye HCs in Elwayee woreda, Surupa HC in Gomole woreda and Moyale HC in Moyale woreda with 87.5%. Laboratory unit is available in most of the Health Centers in Jimma zone but lack of standard operating procedures (SOP), guidelines and lack of laboratory equipment and reagents, staff not maintaining stock balance in the unit were among the challenges that existed in most functional laboratory units. Therefore, Health Centers need to be encouraged to equip the laboratory unit by prioritizing on the business plan, but in a district like Mencho and Tiro-Afeta in most Health Centers the unit was not manned by laboratory technician, due to shortage of trained laboratory technicians in the market. Some health centres need to improve on functionality of their laboratories by making services available during the weekend and after working hours (some health centres have started to do so). In Borana zone the main challenge was with laboratory services which lack qualified staff and as a result majority of the health facilities are not providing this service. In some of the HFs which provide the service mostly laboratory related equipment’s like chemistry analysis machines, fume cupboard and incubators are lacking. The other gap is staffs are not maintaining stock cards of laboratory reagents which should show minimum stocks to ensure the availability of essential reagents. MARCH 2021 © CORDAID 41


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    FIGURE 31 » HEALTH CENTRES QUALITY SCORE FOR LABORATORY SERVICES PER WOREDA JIMMA ZONE BORENA ZONE 100% 100% 21% 80% 36% 43% 80% 0% 19% 45% 36% 60% 21%12% 52% 32% 14% 34% 60% -2% 33% 17% 13% 40% 10% 40% 32% 11% 25% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 Quality in relation to logistics, medicines and supplies services category: This indicator is one of the fairly performing indicators in Jimma and Borana where all woreda recorded remarkable improvement though in Borana one woreda (Guchi) slightly declined in performance and no change was recorded in Wachile. The overall average quality score for this category during the baseline study was 36.4% in Jimma and improved to 74.8% during Q4 2020 while it improved from 67.8% to 76.4% in Borana. The highest average score was 89% in Kersa woreda for this category during Q4 2020 and Gomole with 90% in Jimma and Borana respectively and the lowest were Tiro Afeta in Jimma with 48% and Guchi with 60% average in Borana. Kersa district recorded the highest percentage change of 69% while Tiro Afeta recorded the lowest percentage change of only 4%. In Borana lowest positive change was recorded Dubluq with 5% change and decline was recorded in Guchi with -5%. No change was recorded in Wachile. The better performing HC in Jimma is Wayu HC in Botor Tolay woreda, Serbo and Bulbul HCs in Kersa woreda and Nada Bidaru and Ale HCs in Omo Nada woreda (100%) while in Borana the highest is Tile Mado HC in Moyale Woreda with 100%. This is one of the best performing indicators in Borana zone, in almost all health centres staff know and can clearly explain the drug request mechanism, but lack of cleanliness, cupboard that is lockable, storage of drugs categorically, availability of expired drugs in some Health Centers, and not updating the stock balance as such stock cards do not match the actual counts and shortage of essential tracer drugs are still challenges. In most health centres drugs were also correctly stored, while there were no expired drugs or consumables in the pharmacy during the time of the baseline study. The most challenging aspect for the lowest performing health centres on this category was the management of essential drugs where the Monthly Average Consumption (MAC) was not properly calculated. To avoid any drug shortages or stockouts, it is important that Health Centres will improve this. Additionally, most Health Centres do not register drugs dispensed and the VEN analysis column of dispensary registration not properly filled. This analysis enables the health facilities to compute their consumption rate weekly and continuously update their supply chain management plans accordingly. MARCH 2021 © CORDAID 42


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    FIGURE 32 » HEALTH CENTRES QUALITY SCORE FOR LOGISTICS, MEDICINES AND SUPPLIES PER WOREDA JIMMA ZONE BORENA ZONE 100% 69% 46% 52% 100% 30% 25%43% 5% 8% 0% 27% 80% 31% 35% 36% 42% 80% -5% 6% 0% 20%13% 50% 60% 4% 60% 40% 40% 20% 20% 0% 0% Q4 2020 Baseline Q4 2020 Q3 2019 The performance of the HOSPITALS in relation to the Quality assessments: In general, there was significant improvement in the quality of services at hospital level both in Jimma and Borana (Figure 33). Jimma zone hospitals quality increased from 29% at baseline (Q3 2019) to a high of 74.4% in Q3 2020 before dropping down to 71.3% in the last quarter of 2020 while the Borana zone hospitals quality consistently increased from 64.3% to 91.1% in the same period. There were no quality verifications conducted in all hospitals in Q1 2020 due to Covid-19 and the assessment remained suspended in Moyale Hospital throughout 2020, as the facility was a covid-19 treatment centre which leaves Yabelo as the only hospital in Borana with 91.1% and also as the best performing hospital in the entire PBF program (Figure 34). In Jimma zone, the best performing hospital was Omo Nada hospital with 87% while Setema hospital saw the biggest improvement of 47 percentage points between baseline and Q4 2020 (Figure 34). The least performing hospital in Jimma was Agaro hospital with 59%. Apart from being a newer hospital, the management of the Omo Nada and Yabello hospital seems committed and well organised: most staff in this hospital were showing ownership of the process of improving the quality of services. One best practice noted in Omo Nada and Yabello hospital is that the medical director ensures that the internal quantity and quality verifications are conducted well. What is unique for Yabello general hospital is the management members of the hospital are responsible for allocated quality indicators among themselves and particularly general appearance is owned by CEO of the hospital, that’s why almost all of the Quality indicators raised to above 90% in this hospital. Every time before the PPA verifiers and the ZHD arrive to perform the verifications, they conduct both internal quantity and quality indicators verification among themselves. This already makes all staff members aware of what is expected from their departments. Because of this they put effort into addressing the identified gaps accordingly and this best practice needs to be emulated by other hospitals. MARCH 2021 © CORDAID 43


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    FIGURE 33 » TRENDS IN AVERAGE QUALITY SCORES PER ZONE FOR HOSPITALS FIGURE 34 » OVERALL QUALITY SCORES PER HOSPITALS 100% 14% 90% 43% 80% 46% 70% 47% 26% 60% 0% 50% 40% 30% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Primary Setema Primary Hospital Hospital Hospital General Hospital Hospital Hospital Q4 2020 Baseline/Q3 2019 Comparison of the average quality score per service-category for the HOSPITALS Generally, there was improvement on most of the quality service-categories during the Q4 2020 assessment in Jimma and Borana when compared to the baseline (Q3 2019). In Jimma, the most improvements were noted in the logistics and medicines supply category which improved from 22.5% at baseline to 92.5% in Q4 2020 and for maternity services which improved from 20.8% at baseline to 77.7% in Q4 2020. The lowest improvement was recorded mainly for the categories in surgical services and Lab services although surgical services was the highest performing category in Q4 2020 with a score of 92.6% while the inpatient category was the lowest performer with a score of 43.1%. In Borana, the most improvements were noted in the inpatient service category which improved from 16.7% in Q3 2019 to 100% in Q4 2020 and for general OPD which improved from 50% in Q3 2019 to 100% in Q4 2020. The lowest improvement was recorded mainly in the categories of surgical services and laboratory services which had 14.7 and 4.2 percentage points improvement respectively. Administration, Finance and planning, general appearance, HMIS and supervision, general OPD and emergency services were the highest performing categories with a score of 100% while the laboratory services category was the lowest performer with a score of 66.7%. Further analysis per services category is provided in the below sections. MARCH 2021 © CORDAID 44


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    FIGURE 35 » COMPARISON OF AVERAGE QUALITY SCORE PER SERVICE AREA AT HOSPITALS Quality in relation to the general appearance and safety category per hospital: The overall average quality score for the category of General Appearance during the baseline study was 33.3% in Jimma and improved to 58.3% during Q4 2020 while it improved from 58.3% to 100% in Borana. The highest performing Hospital for this category during Q4 2020 was Omo Nada with 92% average, and Yabello Hospital with 100% in Jimma and Borana respectively and the lowest was 33% in Agaro Hospital in Jimma with. During Q4 2020 there was remarkable improvements across all Hospital in Jimma with Limmu Genet Hospital recording the highest percentage points change of 50% while Agaro Hospital recorded the lowest percentage points change of 8%. In Borana the highest percentage points change of 33% was recorded by Yabello Hospital. Hospital performance under this category is good on availability of signposts, gates, fenced and availability of electricity with backup generators. There is also a functional mobile/landline phone dedicated for communication with health centres for referring patients. While there is some improvement, gaps still exist in Hospitals with regard to cleanliness of the environment, availability of litter, floor that is not clean and cracked, lack of painting and in the least performing Hospitals like Agaro doors and windows were broken not lockable, staff was not wearing a uniform, and wearing of open shoes in Hospital exists. Hospitals need to exert their effort to improve on this indicator. FIGURE 36 » QUALITY SCORE FOR GENERAL APPEARANCE AND SAFETY PER HOSPITAL 100% 33% 90% 25% 80% 70% 50% 60% 0% 17% 50% 40% 8% 30% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Primary Setema Primary Hospital Hospital Hospital General Hospital Hospital Hospital Q4 2020 Baseline/Q3 2019 MARCH 2021 © CORDAID 45


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    Quality in relation to administration, financial management, HRM & planning category per hospital: The overall average quality score for the category administration, financial management, HRM & planning during the baseline study was 20.8% in Jimma and improved to 66.7% during Q4 2020 while it improved from 75% to 100% in Borana. The highest performing Hospital for this category during Q4 2020 was Omo Nada Hospital with 100% average, and Yabello Hospital with 100% in Jimma and Borana respectively and the lowest was 25% in Setema Hospital in Jimma. During Q4 2020 there was 75 percentage points improvement at Omo Nada Hospital in Jimma while Setema Hospital recorded a decline of 8 percentage points. In Borana there was no percentage points change at Yabello Hospital, but Yabello Hospital already reached the highest score of 100%. While there was improvement on annual, quarterly, and monthly plans and report documentation, on displaying Hospital vision, mission and values in appropriate places, posting of staff duty rosters that are visible and accessible to all staff, there is still room for the Hospitals to improve on staff document management like updating staff job description, quarterly Hospital board meetings and producing quarterly progress report. FIGURE 37 » QUALITY SCORE FOR ADMINISTRATION, FINANCIAL MANAGEMENT, HRM AND PLANNING PER HOSPITAL 100% 75% 0% 90% 58% 80% 58% 70% 60% 0% 50% 40% -8% 30% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Primary Setema Primary Hospital Hospital Hospital General Hospital Hospital Hospital Q4 2020 Baseline/Q3 2019 Quality in relation to the HMIS and supervision category per hospital: The overall average quality score for this category during the baseline study was 30% in Jimma and improved to 80% during Q4 2020 while it improved from 75% to 100% in Borana. The highest performing Hospital for this category during Q4 2020 was Omo Nada Hospital with 100% average and Yabello Hospital with 100% in Jimma and Borana respectively and the lowest were Agaro and Setema Hospital in Jimma with 70%. During Q4 2020 there was remarkable improvement at Omo Nada Hospital with highest percentage points change of 80% while Limmu Genet Hospital recorded the lowest percentage points change of 20%. In Borana there was no improvement in both Hospitals, as Yabello Hospital reached the highest score of 100%. This is one of the best performing quality indicator categories in both Borana and Jimma zone, with the performance ranging from 70 to 100%, as such in most hospital the monthly, quarterly report submitted timely both in hard copy and soft copy, the report kept documented chronologically, monthly Hospital monitoring charts were displayed on the wall. There is also a functional Hospital performance monitoring team that meets regularly to assess their performance, but a lack of regular supportive supervision to Health Centers, quarterly self-assessment checklists not filled and documented. MARCH 2021 © CORDAID 46


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    FIGURE 38 » QUALITY SCORE FOR HMIS AND SUPERVISION PER HOSPITAL 100% 80% 0% 90% 80% 20% 30% 70% 70% 60% 0% 50% 40% 30% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Primary Setema Primary Hospital Hospital Hospital General Hospital Hospital Hospital Q4 2020 Baseline/Q3 2019 Quality in relation to the infection control and waste management category per hospital: The overall average quality score for this category during the baseline study was 20.2% in Jimma and improved to 56% during Q4 2020 while it improved from 40.5% to 71.4% in Borana. The highest performing Hospital for this category during Q4 2020 was Omo Nada Hospital with 90% average and Yabello Hospital with 71% in Jimma and Borana respectively and the lowest was Agaro Hospital in Jimma with 29%. During Q4 2020 there was remarkable improvement at Limmu Genet Hospital with highest percentage points change of 57% while Omo Nada Hospital recorded the lowest percentage points change of 19%. In Borana there was improvement at Yabello Hospital with percentage change of 14%. Most Hospitals showed improvement in this category especially in availing infection prevention policy, posting of procedures in delivery, laboratory, emergency rooms and availability of infection prevention committee. However, use of three bin system and waste bin were still huge gaps in infection prevention and waste management. In most Hospitals there were also gaps in lack of cleanliness of the latrine, availability of faecal matters and absence of water near to latrine, availability of sharps, syringes in the compound existed, using three bin system correctly and consistently. This is the lowest score for Yabello hospital from 13 chapters of quality indicators, which is mainly due to lack of three bin system for medical waste management in emergency OPD, injection rooms, and maternity sides, however available at operation theatre and in Inpatient units, and due to lack of 10 lockable latrine of outpatient consultation separately for male and female with 20 litters of water for flushing in the latrines. Therefore, there was emphasise that hospitals need to also invest more on this area and ensure compliance with the IPC guidelines. MARCH 2021 © CORDAID 47


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    FIGURE 39 » QUALITY SCORE FOR INFECTION CONTROL AND WASTE MANAGEMENT PER HOSPITAL 100% 19% 90% 80% 14% 57% 70% 60% 50% 38% 40% 29% 30% 0% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Setema Primary Hospital Hospital Hospital General Hospital Primary Hospital Hospital Q4 2020 Baseline/Q3 2019 Quality in relation to the out-patient department services category per hospital: The overall average quality score for this category during the baseline study was 25% in Jimma and improved to 58.3% during Q4 2020 while it improved from 50% to 100% in Borana. The highest performing Hospital for this category during Q4 2020 was Setema Hospital with 92% average and Yabello Hospital with 100% in Jimma and Borana respectively and the lowest was Limmu Genet Hospital in Jimma with 25%. During Q4 2020 there was remarkable improvements at Setema Hospital with highest percentage change of 75% while Limmu Genet Hospital recorded the lowest percentage change decline of 8%. In Borana there was improvement at Yabello Hospital with percentage change of 25%. Except Yabello Hospital that scored 100%, the other Hospitals need improvement though there was positive side on availability of waiting areas for client that is protected against sun, with sufficient bench, all Hospital have triage with designated Nurses with the consultation room privacy ensured and availabilities of guidelines and equipment like Thermometer, Otoscope, sphygmomanometer, weight scale. But lack of IEC materials at waiting area, lack of water in the consultation room regularly, lack of Post Exposure Prophylaxis (PEP) were still the existing gaps in most Hospitals. FIGURE 40 » QUALITY SCORE FOR OUT PATIENT DEPARTMENT SERVICES PER HOSPITAL 100% 25% 75% 90% 80% 50% 70% 60% 50% 17% 40% -8% 30% 0% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Primary Setema Primary Hospital Hospital Hospital General Hospital Hospital Hospital Q4 2020 Baseline/Q3 2019 MARCH 2021 © CORDAID 48


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    Quality in relation to the maternity service category per hospital: The overall average quality score for this category during the baseline study was 20.8% in Jimma and improved to 77.5% during Q4 2020 while it improved from 81.7% to 90% in Borana. The highest performing Hospital for this category during Q4 2020 was Nada Hospital with 87% average and Yabello Hospital with 90% in Jimma and Borana respectively and the lowest was Setema Hospital in Jimma. During Q4 2020 there were remarkable improvements at Agaro and Limmu Genet Hospital with highest percentage change of 63% while Setema Hospital recorded the lowest percentage change decline of 50%. In Borana there was slight improvement at Yabello Hospital with slight change of 3%. Generally, in most Hospitals there is a separate waiting area that is designated to maternity services, protected against sun, with IEC materials and sufficient benches, the delivery couches are in good state and privacy is ensured by putting screens. In all Hospital delivery rooms there were supply and equipment like baby scale, tape measure, Vit-K, fetoscope, with sterile delivery and episiotomy set and emergency tray available with all drugs and supplies. Beside the availabilities of guideline and service providers can name danger signs during pregnancy, after pregnancy as well as new-born danger signs easily, in most Hospital partographs are used and filled correctly and regularly. But in most Hospitals except Yabello Hospital, there is no working bathroom dedicated to maternal service next to the labour ward, and a latrine is not available, or if it exists it is not clean, no water and soaps. Generally, there is still need to improve on using the partographs properly and as a result the revised checklist now includes checking use of partographs, guidelines/protocols should be made available and prenatal and post-natal rooms need to be cleaned. Hospital management teams should stick to the quality standards. Equipment and instruments should be made available in all delivery rooms and prenatal and postnatal rooms should be separated and cleaned, allowing staff to bring their knowledge into practice. FIGURE 41 » QUALITY SCORE FOR MATERNITY SERVICES PER HOSPITAL 100% 3% 50% 90% 63% 63% 80% 0% 70% 50% 60% 50% 40% 30% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Primary Setema Primary Hospital Hospital Hospital General Hospital Hospital Hospital Q4 2020 Baseline/Q3 2019 Quality in relation to the expanded program on immunization category per hospital: The overall average quality score for this category during the baseline study was 17.5% in Jimma and improved to 60% during Q4 2020 while it improved from 65% to 80% in Borana. The highest performing Hospital for this category during Q4 2020 was Nada Hospital with 80% average and Yabello Hospital with 80% in Jimma and Borana respectively and the lowest were Agaro and Limmu Genet Hospitals Hospital in Jimma with 50% percentage change. During Q4 2020 there were remarkable improvements at Limmu Genet and Setema Hospitals, with the highest percentage change of 50% while Agaro Hospital recorded the lowest percentage change, a decline of 30%. In Borana there was 10% decline at Yabello Hospital in percentage change. Though there were some improvements on this category in most Hospitals by availing guidelines, posting of EPI monitoring charts (though theywere not tallying with tally sheets), EPI reports, availability of antigen with EPI accessories, and by storing antigens correctly based on guidelines, but still gaps existed on monitoring of vaccine wastage, following multi dose policy, and in most Hospitals, there is poor wastage monitoring and vaccine order forms and stock cards are not properly used. Yabello hospitals missed points on this indicator due to absence of vaccine order forms, vaccine stack cards, AEFI Investigation forms and vaccine wastage monitoring forms which leads to poor stack managements. Omo Nada Hospital hospital staff correctly calculates Monthly Average Consumption (MAC) and the refrigerator is clean and kept properly however other hospitals still need to improve in this aspect. MARCH 2021 © CORDAID 49


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    FIGURE 42 » QUALITY SCORE FOR EXPANDED PROGRAM ON IMMUNIZATION PER HOSPITAL 100% -10% 90% 40% 80% 70% 50% 60% 50% 30% 50% 0% 40% 30% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Primary Setema Primary Hospital Hospital Hospital General Hospital Hospital Hospital Q4 2020 Baseline/Q3 2019 Quality in relation to the emergency services category per hospital: The overall average quality score for this category during the baseline study was 23.4% in Jimma and improved to 79.7% during Q4 2020 while it improved from 83.1% to 100% in Borana. The highest performing Hospital for this category during Q4 2020 was Limmu Genet and Yabello Hospital with 100% average in both hospitals in Jimma and Borana respectively and the lowest was Agaro Hospital in Jimma. During Q4 2020 there were remarkable improvements at Limmu Genet and Omo Nada Hospital with highest percentage change of 63% while Agaro Hospital recorded the lowest percentage change decline of 25%. In Borana there was no improvement observed at Yabello Hospital with percentage change of score of 0% as this Hospital reached maximum score of 100%. Although there has been remarkable improvement during 2020, there are still some gaps which need to be fully addressed specifically Agaro Hospital were emergency room was not fully equipped with emergency drugs, materials and supplies: Tracheostomy set, Tracheotomy set, minor surgery set, intubation, and emergency drugs. The specific quantities per set have since been included in the checklist for more objectivity in assessment. Also, the emergency room attendants were not strictly following the infection prevention and waste management procedures though they can name all the risk precaution to avoid bloodborne diseases during knowledge assessment parts. Yabello, Limmu Genet and Omo Nada hospital have made significant progress in addressing most of the gaps which were identified during 2019. FIGURE 43 » QUALITY SCORE FOR EMERGENCY SERVICES PER HOSPITAL 100% 0% 63% 63% 90% 80% 75% 70% 0% 60% 25% 50% 40% 30% 20% 10% 0% Moyale General Yabelo General Agaro General Limmu Genat Omo Nada Primary Setema Primary Hospital Hospital Hospital General Hospital Hospital Hospital Q4 2020 Baseline/Q3 2019 MARCH 2021 © CORDAID 50

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