Quality of Care in Primary Health Care and Referral

Facilities Activity

CONCEPT PAPER

Submitted by the ECBH Project

Date: 1/22/2021

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Country Context and Problem Statement 1

Activity Objective: 4

Results Areas 5
The QOC Activity Theory of Change: 5
Activity Description and Expected Results 6
Local Ownership and Sustainability Error! Bookmark not defined.

Choice of Instrument 14

Project Management Approach Error! Bookmark not defined.

Estimated Cost Error! Bookmark not defined.

Annexes: Error! Bookmark not defined.
Annex 1: Pictorial Result Framework 15
Annex 2: Approach for Targeted Technical Assistance 15
Annex 3: Additional LME and CLA Considerations 16
Illustrative indicators 17

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 A. Country Context and Problem Statement
Country Context:

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

Health context:
Ethiopia Service Delivery Context: Ethiopia’s 1993 Health Policy continues to provide the health
system framework in emphasizing comprehensive primary health care (PHC), including disease
prevention, health promotion, and rehabilitating disabilities 1. The policy also mandates that the Ministry
of Health (MOH) develop health infrastructure, health workforce, and se rvice delivery systems. The
fourth Health Sector Development Plan (HSDP)-IV, 2010/11-2014/15) introduced a three-tiered health
care delivery system as depicted in the diagram below.

Primary health care level consists of a primary hospital, health centers (HC), and satellite health posts
(HP) which together are called Primary Health Care Unit (PHCU) and serve a catchment population of
between 60,000 and 100,000 and are managed by district level health authorities. Secondary care is
delivered by general hospitals with a catchment population of 1.5 million and overseen by regional
health bureau. Tertiary care is provided by specialized hospitals with a catchment population of
approximately 5 million people 2 with regional and federal oversight. The ref erral network is embedded

1 Federal Democratic Republic of Ethiopia (FDRE). Health Policy of the Transitional Government of Ethiopia. Addis Ababa: FDRE;
1993.
2 World Health Organization (2015): Improving health systems efficiency: human resources for health
reforms.Source:https://apps.who.int/iris/bitstream/handle/10665/187240/WHO_HIS_HGF_CaseStudy_15.6_eng.pdf;jsessionid=D40C92
E3C651C56B88DE44C3B00675AA?sequence=1#:~:tex t=HSDP%20IV%20has%20introduced%20a,by%20specialized%20hospitals%2
0(3). Accessed on April 10, 2021.
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in the service delivery systems to link the health facilities within and across different tiers/levels of care.
The preventive, promotive, essential curative and rehabilitative health services are mainly provided at
the PHCU, which is also where USAID has directed its investments over the past decades.

Ethiopia Health System Performance: The 2016 Ethiopia Demographic and Health Survey (EDHS) 3
and the 2019 mini-DHS4 revealed tremendous progress in several health service access, d elivery and
outcome indicators at national level over the last 20 years. However, newborn mortality and nutrition
indicators have stagnated. Moreover, there are significant disparities across regions and also different
population groups that are buried under national aggregate reports. Generally, urban areas have better
health outcomes than rural areas, but women, children, and adolescents living in urban slums appear to
have less access to health services and consequently, suffer poor health outcomes. Comp ared to non‐
slum residents, those living in slums often face worse health outcomes in overall mortality,
maternal and newborn morbidity and mortality, and child mortality as indicated by a study in Kenya
that puts MMR in slums at 706 per 100,000 live births as compared to a national average of 488. 56
Ensuring equitable access to quality healthcare for all Ethiopians is at the heart of a well performing
health system 7, and key for achieving sustainable development goals (SDG) 8. This principle ideally
should guide all investments in public and private health sectors to the benefit of Ethiopian citizens.

Global Definitions on Quality: Currently, there is no universally accepted definition of quality within
the global health community. Health care providers, financers, purchasers, clients, and communities
(i.e., users of health services) have different perceptions regarding the quality of health care. Yet a
standard definition would be critically important to measure, monitor and continuously improve the
quality of health care. The US Institute of Medicine (IOM) issued the guiding definition “the degree to
which health services for individuals and populations increase the likelihood of desired health outcomes
and are consistent with current professional knowledge”,9 which is generally accepted and applied 10 for
measurement, monitoring and improvement of quality of health care.

Berwick, D. et al aptly described in their 2018 article ‘Crossing the global quality chasm: improving
health care worldwide’ that concerns of quality of healthcare exist in all health systems, regardless of
any country's socio-economic and health sector development status. The authors also classified the
difference between the desired and actual health services not as a simple gap but as a “chasm”. Among
the key recommendations included in the report:
● redesigning person-centered healthcare system and improving the patient journey across the life
course
● ensuring health system accountability to the service users
● addressing adverse impacts of corruption
● building health literacy in the community

3 EDHS. Central Statistical Agency [Ethiopia] and ORC Macro. Ethiopia Demographic and Health Survey (EDHS); 2016
4 Ethiopian Public Health Institute (EPHI) [Ethiopia] and ICF. 2019. Ethiopia Mini Demographic a nd Health Survey 2019: Key
Indicators. Rockville, Maryland, USA: EPHI and ICF.
5 AMDD-Urban-MNH-Report_July-20-2016-Final-Report
6 The effect of enhanced public-private partnerships on Maternal, Newborn and child Health Services and outcomes in Nairobi-Kenya the
PAMANECH quasi-experimental research protocol
7 Delivering quality health services: a global imperative for universal health coverage. Geneva: World Health Organization,
Organisation for Economic Co-operation and Development, and The World Bank; 2018. Licence: CC BY-NC-SA 3.0 IGO
8United Nations , The 2030 Agenda for Sustainable Development,https://sdgs.un.org/goals
9 Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Ce ntury. Washington, D.C: National
Academy Press; 2001
10 Ministry of Health (2016): Ethiopia National Health Care Quality Strategy (2016 -2020): Transforming the Quality of Health Care in
Ethiopia
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 ● integrating and coordinating the care
● strengthening public-private partnerships,
● learning and properly incorporate the informal care (self-care/family care) sector,
● creating a culture of learning and use opportunities of increase in availability of digital
technologies11.

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

Based on the HSTP-I priorities and transformation agenda, Ethiopia developed and launched a National
Healthcare Quality Strategy (2016-2020) to guide its planning and implementation of national healthcare
quality improvement practices. The National HealthCare Quality Strategy (NQS) defined quality as a
“comprehensive care that is measurably safe, effective, patient-centered, and uniformly delivered in a
timely way that is affordable to the Ethiopian population and appropriately utilizes resources and
services efficiently” 12. The NQS prioritized maternal, newborn and child health (MNCH), nutrition,
communicable and non-communicable diseases and clinical and surgical services. Building on the NQS,
several quality improvement initiatives were developed and implemented including MNCH Quality of
Care, Saving Lives through Safe Surgery (SaLTS), and the Learning Health Facility 13 to mention a few.
However, these initiatives have narrowly improved QOC, only within their respective technical areas of
focus and associated facilities; consequently, such limited coverage resulted in low nationwide impact.
As a result, assessment of NQS implementation showed only 34 of the 54 interventions (64%) in the
NQS were initiated by 2020.

Institutionalizing QOC interventions requires adequately resourced and empowered structures to

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

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

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

11 Berwick D, Snair M, Nishtar S. Crossing the global health care quality chasm: a key component of universal heal th coverage. Jama.
2018 Oct 2;320(13):1317-8.
12 Federal Democratic Republic of Ethiopia Ministry of Health. Ethiopian National Health Care Quality Strategy, 2016 -2020.
13 Ministry of Health (2019): Ethiopian Health Care Quality Bulletin. Vol 1, May 2019
14Ministry of Health (2020): Review of HSTP-I achievements (situation analysis) for Second Health Sector Transformation Plan (HSTP)

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improved data analysis and use to inform decision making and policy development. Yet, indicators
assessing levels of quality within such care are mostly absent.

The Northern Ethiopia conflict that started in Nov 2020 and is still continuing has resulted in the
destruction of several key infrastructure including health facilities resulting in limited health access to
millions of people in Tigray, Amhara and Afar. This would require a concerted effort to bring back the
health system in these regions to the level before the conflict and ensure delivery of quality RMNCH
services.
Problem Statement
Ethiopia has developed service quality standards for maternal and newborn health services; however,
several challenges have impeded the implementation of these standards. There is poor governance and
coordination within PHCUs and referral facilities as well as at various levels of the health system that
are responsible for quality improvement to tackle the QOC bottlenecks.

The maternal, newborn and child health service quality standards developed by MOH were not widely
used due to several factors including inadequate understanding of healthcare quality concept and limited
practices, weak organization and delivery of health care services, communities’ preference for secondary
and tertiary level care and bypassing the primary healthcare level. Additionally, shortage of competent
and motivated care providers, essential drugs, medical equipment and technologies; poor infrastructure,
weak referral and service integration across components within and along the continuum of care, and
weak data use for improvement were identified. Poor infrastructure including insufficient power with
unreliable electric supply, lack of consistent water supply and poor sanitary facilities 15,16, and weak
internet connectivity are other impediments for quality improvement efforts and implementation of
NQS.

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

15 Ethiopia Service Availability and readiness Assessment (SARA), 2018

16 FMOH. Review of National Health Care Quality Strategy (2016 – 2020), Draft report, April 2020
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adolescent girls and children by increasing readiness of the health facilities and delivery of quality,
patient-centered RMNCAH care by increasing competency and performance of healthcare providers and
managers, strengthening systems for feedback and accountability and enhancing community
participation thereby increasing client satisfaction and service utilization and ultimately prevent
maternal and child mortality. The activity will also support restoration of he alth services in conflict
affected areas by rehabilitation and equipping of damaged facilities.

Results Areas17
IR. 1 Readiness for and delivery of Quality RMNACH Services Improved
SubIR 1.1. Health facilities are capable of fulfilling all required inputs to deliver quality RMNCH
services.
SubIR 1.2: Competency of healthcare providers improved 18
SubIR 1.3. Delivery of client- centered care through continuous quality improvement (CQI)
ensured
SubIR 1.4. Referral systems and networks are functional and coordinated

IR 2. Management and Accountability for Quality Service Delivery Strengthened

SubIR 2.1. Structure 19 and Systems20 for Healthcare Quality Improved
SubIR 2.2. Generation and use of evidence to improve Quality of RMNCAH servic es increased
SubIR 2.3. Community representation and engagement on CQI at health facilities increased
IR 3. Health services restored in health facilities in conflict affected areas
SubIR 3.1. Select damaged health facilities are rehabilitated
SubIR 3.2. Essential health service provision restored in rehabilitated facilities
SubIR 3.3.QOC systems established and maintained in health facilities affected by the conflict

The QOC Activity Theory of Change:

IF the readiness of health facilities for delivery of quality RMNACH service is improved; and
IF management and accountability for quality service delivery increased; and
IF health services restored in health facilities in conflict affected areas.

Assuming that,
PHCUs and referral facilities consistently utilize their increased capacity to continuously improve
QOC of RMNCH services.
Resources to resolve bottlenecks for RMNCAH quality services are availed by and for the facilities.
Other USG and non-USG-supported health system activities are successful in co-leveraging their
investments for a well-functioning health system; and

17 see annex1 for result framework

18 Service Provider Capacity (competency, skill, compliance), motivation and performance Strengthened to Align to National Clini cal
Protocols (Quality, Child Health, Newborn Health, Maternal Health, FP/SRH )
19 Structure stands for unit or team in -charge of quality of healthcare
20 System stands for: QoC standards, guidelines, data management systems, plan -performance review and feedback
system, Accountability mechanism etc
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Peace is restored in the conflict affected areas

THEN the quality improvement efforts will be sustained; and the quality of RMNCAH services will be
enhanced for improved client satisfaction and health services utilization leading to improved health
outcomes.
C. Activity Description and Expected Results
This activity falls under USAID/Ethiopia’s Development Objective 4 (DO4) that aims to advance
gender-equitable essential service outcomes and directly contributes to its two health projects,
Empowered Communities for Better Health (ECBH) and the Health System Strengthening (HSS)
Projects. ECBH is the primary/home project for this activity.

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

The Activity will build on the gains of the RMNCAH flagship activity of TPHC and will be implemented
in seven regions: Tigray, Amhara, Benishangul Gumuz, Oromia, Sidama, South Western Ethiopia and
SNNPR. Final decisions on geographic selection will be made after a thorough review of relevant data
and receipt of post-conflict assessments. Besides, Secondary cities aligned with the Alternative Growth
poles21 will be prioritized for targeting by the activity.
The activity will have integration and layering with ongoing and new activities under the HSS and
ECBH projects including Empowered Communities, social and behavior change communication
(SBCH), Supply chain, Health Workforce Improvement Program (HWIP), Health Financing
Improvement Program (HFIP), Multisectoral Nutrition, and Digital Health Activity etc and the WASH
project to leverage support for facility access to ensure inputs and systems are strengthened as well as
access to WASH infrastructure as well as technical assistance. The activity will be fle xible to identify,
assess and support responses to any man made or natural disasters including disease outbreaks, drought,
conflict etc. that affect the health of the target population to protect the gains in its development work
and save lives of mothers and children. The activity will have specific agreed upon criteria to ensure the
assistance provided is tailor made to the need of the facilities and the gaps they have. Facilities will put
under four tiers based on their status at the start of the activity with Tier 0 being facilities in conflict
affected geographies; Tier 1 which did not have previous USAID support, high -volume facility, high
maternal and or newborn/child death rates OR other related RMNACH indicators; Tier 2 historically
USAID supported ones and Tier 3 facilities at a level of network of excellence (See Annex 2). For
conflict affected areas as well as others the activity will leverage additional resources and technical
expertise to ensure efficient utilization of limited resources.

21 Alternate Growth pole final report, June 2021

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IR. 1 Readiness for and delivery of Quality of RMNCAH Service Improved
Health facility readiness refers to the capacity of health facilities to provide a specific service to the
public, and measured through the presence of tracer items. The tracer items to measure health facility
readiness include infrastructure and basic amenities22, availability of trained health care providers and
managers, equipment, and essential supplies, medicines and diagnostic capacities to provide basic
health-care interventions23,24 According to Ethiopia's Service Availability and Readiness Assessment
(SARA, 2016), only 7 percent of the facilities have fulfilled all the tracer items for readiness to provide
family planning services, and an average availability of the 8 tracer items is 64 percent. In addition, the
availability of at least one trained staff on family planning was observed in less than 60 percent of health
facilities. The gender mix of health facility staff is also unbalanced.

Sub IR 1.1: Health facilities fulfill all required inputs for delivery of quality RMNCAH services.
This activity will ensure facilities’ capacity to plan and mobilize stakeholders and resources that can
support availability of essential amenities and inputs to deliver sustainable quality RMNCAH serv ices.

Expected results
● Facilities are able to avail basic amenities, equipment, essential medicine and diagnostic capacity
● Capacity for installation, management and equipment maintenance increased
● Capacity of health facilities for supply chain functions [forecasting, projection, planning,
requesting/procurement, and monitoring and reporting stock level etc] for essential medicine and
diagnostics improved
Sub IR 1.2. Competency of healthcare providers in RMNCAH improved
This sub-result aims to ensure facilities, especially high burden urban and peri urban PHCUs and referral
facilities including private health facilities, adopt and institutionalize use of established RMNCAH
standards to improve and sustain QOC across service delivery units to reduce maternal and child
mortality.

Expected results
● HWs’ capacity on RMNCAH QOC standards is built
● HWs provided supervision, mentorship and technical support to adopt and use the QOC
standards for RMNCAH at health facilities
● Improved provision of RMNCAH services as per the national standards

Sub IR 1.3. Delivery of Client Centered Care through Continuous Quality Improvement (CQI)
ensured
Ensuring the voice of communities and clients heard through collecting and integrating feedback from
clients and communities is important in improving QoC and building trust between healthcare
providers and users. Gender and youth sensitive service provision has a high impact in ensuring better

22 Basic amenities assessed based on the availability of the following tracer items: power (grid or generator), communication
equipment, consultation room, improved water source, adequate sanitation faci lities, and computer with internet access, and
emergency transportation
23 Ministry of Health (2017): ETHIOPIA Services Availability and Readiness Assessm ent 2016; Comprehensive Report, January 2017 .
24 Manu et al (2018): Assessment of facility readiness for implementing the WHO/UNICEF standards for improvin g quality of maternal
and newborn care in health facilities – experiences from UNICEF’s implementation in three countries of South Asia and sub -Saharan
Africa. BMC Health Services Research (2018) 18:531

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utilization of services.

Expected results
● Functionality of QI/Performance Management Teams in health facilities including private health
facilities improved
● Improved functionality of Patient Care/Advocate Feedback Platform (tools, forums,
operations) for delivery of quality RMNCAH services
● Improved Awareness and solution by Provider and Manager to client Feedback
● Improved Youth and women friendly service provision
● Health facilities consistently score Green (commendable score) in the national QOC standard
measures

Sub IR 1.4. Referral Systems and Networks are Functional and coordinated
The activity will support a streamlined, bi-directional referral system to facilitate efficient referral
pathways across primary, secondary and tertiary levels of the health system and QOC in higher level
facilities including private health facilities for better RMNCAH outcomes.

Expected Results
● Seamless and effective 25 cross-directional referral networks for RMNCAH services across
communities, PHCUs and referral facilities including private health facilities in place
● Established referral audit / accountability system for documentation, monitoring and evaluation
of patient referral protocol implementation and end patient outcomes
● Critical patients are provided with the appropriate care by qualified and experienced team
while being transported safely and efficiently
● Referral service provision is women and child friendly

IR 2. Management and Accountability for Quality Service Delivery Increased

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

Sub IR 2.1. Structure and Systems for Healthcare Quality Improved

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

25 patients get the required assessment and determination for referral, counseled adequately about to accept referral and their referral to
the the referral facility done timely to get the best care possible and the referring facility gets the full information abou t the progress and
any follow up need after that
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Expected results:
Leadership capacity26 of managers of districts, PHCU and referral facilities including private health
facilities improved.
● Improved effective monitoring of quality standard in addition to coverage of services by health
facility leadership.
● QOC units at PHCU and referral facilities established/strengthened to fulf il mandates; and
● Inter-department coordination within PHCUs and referral facilities including private health
facilities strengthened to improve QOC
● Improved participation of Women health workers in leadership roles

Sub IR 2.2. Generation and Use of Evidence to improve Quality of RMNCAH Increased
Availability and use of timely quality data are key for evidence-informed decision making in planning
of all aspects of sustainable country-led quality improvement and management initiatives.

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

Expected Results:
● Capacity of the quality improvement committees at PHCUs and referral facilities including
private health facilities on evidence generation and data use for decision making improved.
● Facility-level platform to coordinate evidence synthesis, research uptake and utilization for
QOC programming established/strengthened
● Data systems at service delivery points and districts (HMIS/DHIS2, eCHIS, EMR, LMIS, etc.)
strengthened to inform quality improvement/ management initiatives.

Sub IR 2.3. Community representation and engagement on CQI at health facilities increased
Community engagement for responsible stewardship is critical to improved accountability,
sustainability and to addressing the increasing demand for quality care. 27

Expected results
● Increased proportion of health facility management committees with community member
representation (particularly females);
● Community-facility platforms effectively assess and address client/community feedback
● Community-health facility interface platforms utilized well for QoC;
● Increased patient satisfaction with the services in the PHCUs and referral facilities

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

26 Leadership capacity: One’s individual knowledge, skills and abilities to manage people and resources
ef f ectively (to meet the results outlined in this concept note include improved health outcomes, no stock-out,
etc) as per X standar
27 Wereta, T., Betemariam, W., Karim, A.M. et al. Effects of a participatory community quality improvement strategy on improving
household and provider health care behaviors and practices: a propensity score analysis. BMC Pregnancy Childbirth 18, 364 (2018).
https://doi.org/10.1186/s12884-018-1977-9
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Thousands of health facilities have been damaged and looted in the war affected areas and access to
health care for the population in this conflict affected areas has become a huge challenge. This activity
will rehabilitate selected health facilities in areas affected by the war and support restoration of health
service provision. In addition, the activity will work towards ensuring the health servic es provided in
these facilities are of optimum quality by establishing and strengthening systems for continuous quality
improvement.

Sub IR 3.1. Selected Damaged Health Facilities are Rehabilitated

The activity will rehabilitate selected health facilities in conflict affected areas of Amhara and Tigray
regions in woredas where this activity will be operating as per national standards.
Expected Results
● The selected health facilities are fully renovated including electrification (solar panels) and
water supply in limited facilities
● Renovated facilities have strong maintenance plan that would help in sustainable infrastructure
management

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

As health facilities have been damaged and all that was in them was looted and damaged health services
are interrupted.
This sub-IR aims at supporting the resuming of essential health services in the renovated health facilities
including RMNCH services.
Expected Results
● The right mix of health workers in terms of gender and profession are deployed and supported
to resume provision of health services in the renovated health facilities
● Renovated health facilities are stocked with basic medical equipment, supplies, drugs and HF
furniture to resume health care service provision
● Community mobilized to utilize health care services from these renovated health facilities

Sub IR 3.3. QOC systems established and maintained in health facilities affected by the conflict
Once health care service provision in the renovated health facilities is resumed, there is a need to ensure
continued quality improvement procedures and processes. This sub-IR aims at ensuring CQI systems
are instituted and sustained in these renovated health facilities.
Expected Results
● Leadership and management capacity for quality of care at the renovated health facilities
improved
● Health workers competency for quality of care at the renovated health facilities improved
● Referral systems and network in the renovated health facilities are instituted and strengthened
● Health facilities are able to fulfil the QOC standards to their level

D. Local Ownership and Sustainability

The Quality-of-Care activity focuses on establishing and strengthening a system for standardization of
RMNCAH services in the public and private health systems utilizing existing GOE structures. The
activity will work to ensure PHCUs and referral facilities own the standardization of services, provision
of these services as per the standard and use existing monitoring mechanisms to ensure that they are
adhered to. Also, this activity will support a stronger coordination among RMNCAH and other units in
facilities to ensure better ownership and sustained results. These approaches address the major problem
that has been identified as a major area of concern in the HSTP as well as the evaluation of the National
Health Service Quality Strategy. Besides, the activity ensures strong collaboration among various health
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facilities through mentorship and collaborative programs and will ensure strong partnership with
educational establishments in each region. These collaboration and partnership will ensure mobilization
of technical support to the facilities; sustain stronger referral systems as well as institutionalized
normative change on how to provide quality care. The activity will also help facilities to identify areas
of need, mobilize resources to cover these gaps in a sustainable ma nner. The activity will support
innovative and locally led interventions like the family health team approach and utilize Private Health
facilities network and associations to enroll private health facilities for this activity.
E. Summary of Conclusion and Analyses
The summary and conclusion of our analysis below is based on analysis of findings from the multiple
consultations done with various relevant stakeholders including relevant FMOH people, Regional
Health Bureaus, Implementing Partners etc. We also have made a systematic review of key international
and nationally seasoned evidence on the field and performance and evaluation reports. A more detailed
summary of the findings and the conclusion of the analysis is annexed.

The Lancet Global Health Commission: The Lancet Quality Commission report identified that the
care people receive is often inadequate, and poor-quality care and that the most vulnerable populations
are faring the worst. It stated that high-quality health systems could save over 8 million lives each year
in LMICs. It recommends that health systems should measure and report what matters most to people,
such as competent care, user experience, health outcomes, and confidence in the system. To address the
scale and range of quality deficits the commission documented, reforming the foundations of the health
system is required. The Commission endorsed four universal actions to raise quality across the health
system. First, health system leaders need to govern for quality by adopting a shared vision of quality
care, a clear quality strategy, strong regulation, and continuous learning. Second, countries should
redesign service delivery to maximize health outcomes rather than geographical access to services alone.
Third, countries should transform the health workforce by adopting competency-based clinical
education, introducing training in ethics and respectful care, and better supporting and respecting all
workers to deliver the best care possible. Fourth, governments and civil society should ignite de mand
for quality in the population to empower people to hold systems accountable and actively seek high -
quality care.

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

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National Health Care Quality Strategy: The National Health Care Quality Strategy focused on
improving quality across the spectrum of the healthcare system from prevention to palliative care, with
special emphasis on the priority public health areas including MNCH, specifically reducing maternal
and neonatal mortality and malnutrition, especially the prevention and management of Severe Acute
Malnutrition (SAM). A review of implementation of the NHSQ showed that many within MOH, RHB
and facilities partners and professional associations are not fully aware of the content and in some
cases not seeing the document or heard about it. The review also indicated that the strategy lacks
clarity in priority interventions, proposed quality structures and responsibilities. Even though most of
the interventions under each strategic focus area are initiated, few are completed. Most services are not
responsive to the user’s needs; very little is done to activate patient and community demand for quality
services and provision of patient centered care; and linkage with relevant health agencies including the
Health Insurance Agency is not yet happening. Efforts are observed to use data for improvement and
decision making but overall practice needs more intervention to maximize the efforts and
institutionalize in the system.

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

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

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

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Office developed an umbrella IEE covering all activities, including the Primary Health Care Unit
(PHCU) now named as Primary Health Care QOC activity, under the Increased Utilization of Quality
under the Health Services Development Objective (DO2). The DO2 IEE was amended to extend the
validity of the IEE till 2024 HERE. The IEE gave a Negative Determination with condition threshold
decision. Accordingly, the Implementing Partner (IP) developed an Environmental Mitigation and
Monitoring Plan (EMMP) and regularly reported on compliance status through a formal
Environmental Mitigations and Monitoring Report (EMMR). As the amended IEE expires before the
end of this activity, the COR for this activity should work with the MEO to prepare an amendment to
extend the validity of the IEE in early 2024. A climate risk analysis has been prepared for all activities
under the ECBH project. The climate risk analysis established that climate risks were low for all
project elements including the Quality-of-Care activity. Accordingly, no further climate risk
management is required for the Quality-of-Care activity.
F. LME and CLA Considerations
The activity will support strengthening of evidence generation and utilization efforts of the health system
to ensure better QOC in RMNCAH services using routine data systems as well as specific operation
research. The activity will leverage the efforts of actors supporting the routine health information system
to inculcate QOC data points and indicators to institutionalize evidence generation and utilization for
QOC in RMNCAH and accountability systems.

The activity should utilize a systematic process of collecting and analysis of performance data and other
information such as qualitative insights, data collection on a more ad hoc basis, or more in -depth
exploration into the achievement of results. The activity’s monitoring approach should demonstrate the
“what, how and when” the implementing partner measures and analyzes data to inform judgments about
the outputs and outcomes of the intervention as a basis to improve effectiveness and/or inform decisions.
Monitoring will also include programmatic assumptions and the operational context of the activity in
order to recognize trends and shifts in external factors that might affect the activity’s performance. It is
also critical to demonstrate monitoring efforts that will be used to identify any gender gaps. The
monitoring plan should also explain how the implementing partner plans to ensure data quality to fit-
for-purpose. The recipient will develop a monitoring plan that includes performance indicators;
description of each indicator including baseline data; targets; and Performance Indicator Reference
Sheets (PIRS).

The recipient should also include a midterm or/and final performance evaluation plan; and a baseline
status may be documented from secondary data sources or with additional primary data; and show if
they intend to conduct an internal evaluation using its own staff or a contractor. USAID will conduct an
independent evaluation on this activity. The plan should identify all evaluations that the partner will
manage over the life of the activity and should include information on the type of evaluation
(performance or outcome/impact); purpose and expected use, possible evaluation questions, estimated
budget, and expected level of USAID involvement, such as reviewing an evaluation statement of work
(SOW) or a draft report.

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 G. Choice of Instrument

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

H. Project Management Approach

The potential awardee will present a detailed human resource management plan to deliver the expected
results under this activity. The key staff mix shall include chief of party, technical director, senior
Quality of Care expert, MEL director, and one other staff that the potential IP proposes to be a key staff
member. The potential awardee will present a conflict sensitive approach and show experience in
implementing interventions in conflict environments. The activity is going to be managed under the
ECBH project and an AOR will be assigned from the ECBH project team and alternate AOR from the
HSS project to ensure proper linkage between the two health project teams. The AOR will work with
the Project lead to establish an activity oversight team that is composed of experts from Supply chain
cluster, Information System cluster, Human Resources for Health team, Child health and Primary health
Cluster for better technical support and monitoring. The Activity will work with the SBCH andh,
Empowered Communities under ECBH and HWIP and Digital Health Activity (DHA) under the HSS
project for improved health system performance management, particularly at primary health care levels.
I. Estimated Cost
The Estimated Cost (TEC) of the activity is $70 million contingent upon availability of supplementary,
post-conflict funding to support Objective 3: Rehabilitation and Restoration activities. However, if
supplementary funding is not received, the true TEC is around $44 million and 10% of the budget
would be dedicated to Objective 3.

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Annexes:

Annex 1: Pictorial Result Framework

Annex 2: Approach for Targeted Technical Assistance

The activity will have specific agreed upon criteria to ensure the assistance provided is tailor made to
the need of the facilities and the gaps they have. Given limited resources for this activity, support will
be selective and collaborate with existing and new activities coming on board. There will be four tiers
of facilities that will get the support from this activity. The lowest tier (Tier 0) includes facilities that
are found in the conflict affected areas and have been damaged and require renovation of the
infrastructure and restoration of services. These facilities will be the targets for interventions under
result 3 where rehabilitation of facility infrastructure, restoration of services will be prioritized and
will be provided the support to improve the quality of care when they are up and running. The second
tier (Tier 1) are facilities which did have limited USAID support or had no previous support and have
the lowest RMNCAH performance. These facilities will get intensive technical assistance across result
1 and 2 to ensure they are able to provide comprehensive client centered RMNCAH services at the
highest quality standards. The third categories of the facilities (Tier 2) are facilities who had
historically been supported through USAID programming and are on the right track to be high
performing facilities. The facilities will get light touch support to ensure gains are sustained and are
able to continue to move the RMNCAH services in the right track. The highest tier (Tier 3) has already
achieved the required results that is being put in the activity concept note but will be included in the
activity to ensure sustainable twinning and collaboration is created with other tier facilities to improve
their performance and create a sustainable quality improvement collaborative that can continue after
the end of the activity. The disaggregation of the facilities into the various levels will be done based on
assessments done by existing USAID funded activities, GOE transformation assessment, RMNCAH
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performance reports from DHIS 2 as well as other HC/Hospital standards on infrastructure and
RMNCAH Quality standards. We will also ensure the TA will be driven by data that assesses
competence, skills and knowledge of health workers and leaders, system status o f the facilities in
terms of compliance with standards, Inputs i.e. basic Infrastructure equipment, information system
functionality and the ability of the facilities to implement Standards. All facilities: HPs, HCs and
hospitals in urban settings as well as HCs and Hospitals in semiurban settings will be targets for this
activity.
Building on previous investments: Targeted TA

Tier Description Package of Support Metrics to Define

Standards Per
Tiers

Tier 0 Conflict Affected Health Facilities Infrastructure, Specific

Rehabilitation, X, Y, Z Assessments

Tier 1 No previous USAID support, high- Intensive TA across all DHIS 2 and
volume facility, high maternal and results previous activity
or newborn/child death rates OR reports
other related RMNACH indicators
Demonstration Sites (HEP
alignment): New ideas for testing

Tier 2 Historical USAID support through Lighter touch TA TPHC and THDR
T/PHC or THDR (BG) reports

Tier 3 Network of Excellence Met all results TPHC and THDR,

National QOC
assessment reports

Annex 3: Additional LME and CLA Considerations

Learning should guide performance management planning by setting learning and information priorities.
It helps in assessing the relevance and adequacy of the theory of change, identifies critical learning gaps
important for successful program implementation; reviews the validity of assumptions; and monitors the
risks. As described in the DO4 project description, the Health Systems Strengthening (HSS) and
Empowered Communities for Better Health (ECBH) projects are two mutually dependent projects that
reinforcing in their support of a comprehensive approach to support the advancement of Ethiopian health
system.
Among a list of illustrative evaluation questions, in particular the question of to what extent did the
project contribute to the overall accountability and responsiveness of service providers and decision
makers to community health needs, is a critical question for this activity. Also the DO4 learning question
around improvement of service delivery systems and if services have become more resilient and
sustainable will be part of the learning question for this activity. The Health Office seeks to promote
learning across stakeholders that are involved with or are affected by the implementation of activities
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under the two PADS through CLA management. Project and activity learning is intended to benefit all
stakeholders.

To achieve these objectives of the health PAD, and fulfil its purposes under its different activities,
indicators are already outlined in the Health Office PADs Joint Project LME plan. Taking this plan and
the list of indicators as a reference the potential applicant is expected to utilize var ious robust
methodologies to generate knowledge, share knowledge and incorporate agile and adaptive processes,
which are the three objectives of the Health PAD. Utilization of quality RMNCAH services is one of
the indicators proposed to be utilized for this activity and ensuring contribution to ECBH project.

For example, to monitor the changes overtime, baseline values will be determined and then LOP targets
and control group/comparison group etc. will be set. Various data sources will be explored to get
baseline values in order to avoid duplication efforts and minimize the costs of data collection. However,
as most of the custom indicators are new it is inevitable that establishment of the baseline values requires
primary data collection. LOTSs Quality Assurance Sampling (LQAS), random follow up visits and
other data collection methods will be employed by the activity to fill the data gap. Once baseline values
are available for the project indicators reasonable LOP targets will be set.

Development Information Solution (DIS)

Implementing partners utilize the Development Information Solution (DIS) as the performance
management information system to track activities’ performance, knowledge, and best practices. After
this activity is awarded, USAID AOR/COR/AM will ensure that information is kept up to date with
necessary activity level data and information, including location of the activity and geospatial
coordinates of sites/services related to the Activity are entered into the system. The IP will closely work
with the AOR/COR/AM to ensure that at least a quarterly update of information is entered into the DIS.

Geographic Information Systems

Utilizing GIS technology and tools, geographic data, and analysis are very essential to effectively
achieve the Mission’s goal of strategically allocating resources through geographically targeting aid
investments, monitoring, and evaluating overall aid effectiveness, and upholding the Agency’s open
data and transparency goals in Ethiopia. Therefore, the prospective Implementing partner should apply
geospatial methods using GIS technology and tools to support USAID’s goal. Once awarded, the
recipient must include geographic data collection, analysis, and submission methods in the CLA Plan
and Work Plans as separate sections.

Illustrative indicators
IR. 1 Readiness for and delivery of Quality RMNACH Services Improved
● Proportion of health facilities that have all the relevant national QI standards and guidelines.
● Percentage of accurate delivery of required clinical actions for i.e. normal delivery, emergency
delivery, newborn care, etc
● Percentage of health workers who are able to provide accurate diagnosis, etc. , increase patient
retention/completion of care
● Stock out rate of essential medicines in target facilities
● Proportion of health facilities that have all the signal functions (BEmONC)s

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 ● Number of health facilities successfully implementing relevant QI initiatives
● Proportion of health facilities that consistently use client centered standards of care for each of
the RMNCAH-N thematic areas
● Proportion of healthcare providers that scored/demonstrated satisfactory level of competency in
their assigned RMNCAH-N thematic areas.
● Number of health service delivery points referring and receiving clients as per the standard
referral and network guidance.
● Number of health facilities (PHCUs) that have established referral audit / accountability system
for documentation, monitoring and evaluation of patient referral protocol implementation and
end patient outcomes
● Percentage of patients that require referral who successfully were referred to higher level care
and gotten positive outcome
IR 2. Management and Accountability
● Proportion/number of quality improvement units established/strengthened.
● Number of evidence generated and used to inform quality improvement in RMNCAH services;
● Proportion of CQI teams and units that have community representation and engagement
● Percentage of Health Centers (HC) and referral hospitals with high performance (>=80%) as
measured by Ethiopian Health Center Reform Implementation Guideline (EHCRIG) score
● Rate of satisfaction and patient positive experience (testing new metrics), i.e. digital surveys
upon exit from facility,

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

● Number of damaged health facilities that are rehabilitated.
● Proportion of health facilities that started providing essential health services after they are
rehabilitated
● Proportion of health facilities with functional continuous quality improvement team
● Number of health facilities successfully implementing relevant QI initiatives

Additional F Indicators (Global)

Indicator ID (IR Indicator
and Sub IR)

HL -4 (IR 1 Sub Average of the service gaps between:

IRs 3.2 & 3.3) a) ANC1 and ANC4;
b) DPT1 and DPT3*, in USAID-supported districts

HL-6.1 (IR 1 Sub Estimated potential beneficiary population for maternal, newborn and child
IRs 3.2 & 3.3) survival program: number of live births.

HL2. 6.1 (IR 1 Sub Number of women giving birth who received uterotonic in the third stage of
IRs 3.2 & 3.3) labor (OR immediately after birth) through USG-supported programs

HL 6.3.1 (IR 1 Sub Number of newborns not breathing at birth who were resuscitated in USG-
IRs 3.2 & 3.3) supported programs

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HL 6.3.63 (IR 1 Number of newborns who received postnatal care within two days of
Sub IRs 3.2 & 3.3) childbirth in USG-supported programs.

HL 6.2.2 (IR 1 Sub Number of women giving birth in a health facility receiving USG support
IRs 3.2 & 3.3)

HL 6.4.62 (IR 1 Number of children who received their first dose of measles-containing
Sub IRs 3.2 & 3.3) vaccine (MCV1) by 12 months of age in USG-assisted programs

HL.6.6.64 (IR 1 Number of cases of childhood pneumonia treated in USG-assisted programs

Sub IRs 3.2 & 3.3)

HL.7.1.1 (IR 1 Sub Couple Years Protection in USG supported programs

IRs 3.2 & 3.3)

HL7.1.2 (IR 1 Sub Percent of USG-assisted service delivery sites providing FP counseling and/or
IRs 3.2 & 3.3) services

HL.7.1.3 (IR 1, Sub Average stockout rate of contraceptives at SDPsby family planning method
IRs 2.1, 3.2 & 3.3)

CBLD-9 (IR 2) Percent of USG-assisted organizations with improved performance

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