Learning from Ethiopia's success in reducing maternal and neonatal mortality through a health systems lens

BACKGROUND

This study aimed to enhance insights into the key characteristics of maternal and neonatal mortality declines in Ethiopia, conducted as part of a seven-country study on Maternal and Newborn Health (MNH) Exemplars.

METHODS

We synthesised key indicators for 2000, 2010 and 2020 and contextualised those with typical country values in a global five-phase model for a maternal, stillbirth and neonatal mortality transition. We reviewed health system changes relevant to MNH over the period 2000-2020, focusing on governance, financing, workforce and infrastructure, and assessed trends in mortality, service coverage and systems by region. We analysed data from five national surveys, health facility assessments, global estimates and government databases and reports on health policies, infrastructure and workforce.

RESULTS

Ethiopia progressed from the highest mortality phase to the third phase, accompanied by typical changes in terms of fertility decline and health system strengthening, especially health infrastructure and workforce. For health coverage and financing indicators, Ethiopia progressed but remained lower than typical in the transition model. Maternal and neonatal mortality declines and intervention coverage increases were greater after 2010 than during 2000-2010. Similar patterns were observed in most regions of Ethiopia, though regional gaps persisted for many indicators. Ethiopia's progress is characterised by a well-coordinated and government-led system prioritising first maternal and later neonatal health, resulting major increases in access to services by improving infrastructure and workforce from 2008, combined with widespread community actions to generate service demand.

CONCLUSION

Ethiopia has achieved one of the fastest declines in mortality in sub-Saharan Africa, with major intervention coverage increases, especially from 2010. Starting from a weak health infrastructure and low coverage, Ethiopia's comprehensive approach provides valuable lessons for other low-income countries. Major increases towards universal coverage of interventions, including emergency care, are critical to further reduce mortality and advance the mortality transition.

Effective coverage of antenatal care services in Ethiopia: a population-based cross-sectional study

BACKGROUND

Antenatal care (ANC) is a principal component of safe motherhood and reproductive health strategies across the continuum of care. Although the coverage of antenatal care visits has increased in Ethiopia, there needs to be more evidence of effective coverage of antenatal care. The 'effective coverage' concept can pinpoint where action is required to improve high-quality coverage in Ethiopia. Effective coverage indicates a health system's performance by incorporating need, utilization, and quality into a single measurement. The concept includes the number of contacts, facility readiness, interventions received, and components of services received. This study aimed to measure effective antenatal care coverage in Ethiopia.

METHODS

A two-stage cluster sampling method was used and included 2714 women aged 15-49 years and 462 health facilities from six Ethiopian regions from October 2019 to January 2020. The effective coverage cascade was analyzed among the targeted women by computing the proportion who received four or more antenatal care visits where the necessary inputs were available, received iron-folate supplementation and two doses of tetanus vaccination according to process quality components of antenatal care services.

RESULTS

Of all women, 40% (95%CI; 38, 43) had four or more visits, ranging from 3% in Afar to 74% in Addis Ababa. The overall mean health facility readiness score of the facilities serving these women was 70%, the vaccination and iron-folate supplementation coverage was 26%, and the ANC process quality was 64%. As reported by women, the least score was given to the quality component of discussing birth preparedness and complication readiness with providers. In the effective coverage cascade, the input-adjusted, intervention-adjusted, and quality-adjusted antenatal coverage estimates were 28%, 18%, and 12%, respectively.

CONCLUSION

The overall effective ANC coverage was low, primarily due to a considerable drop in the proportion of women who completed four or more ANC visits. Improving quality of services is crucial to increase ANC up take and completion of the recommended visits along with interventions increasing women's awareness.

Reducing the equity gap in under-5 mortality through an innovative community health program in Ethiopia: an implementation research study

BACKGROUND

The Ethiopian government implemented a national community health program, the Health Extension Program (HEP), to provide community-based health services to address persisting access-related barriers to care using health extension workers (HEWs). We used implementation research to understand how Ethiopia leveraged the HEP to widely implement evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) and address health inequities.

METHODS

This study was part of a six-country case study series using implementation research to understand how countries implemented EBIs between 2000-2015. Our mixed-methods research was informed by a hybrid implementation science framework using desk review of published and gray literature, analysis of existing data sources, and 11 key informant interviews. We used implementation of pneumococcal conjugate vaccine (PCV-10) and integrated community case management (iCCM) to illustrate Ethiopia's ability to rapidly integrate interventions into existing systems at a national level through leveraging the HEP and other implementation strategies and contextual factors which influenced implementation outcomes.

RESULTS

Ethiopia implemented numerous EBIs known to address leading causes of U5M, leveraging the HEP as a platform for delivery to successfully introduce and scale new EBIs nationally. By 2014/15, estimated coverage of three doses of PCV-10 was at 76%, with high acceptability (nearly 100%) of vaccines in the community. Between 2000 and 2015, we found evidence of improved care-seeking; coverage of oral rehydration solution for treatment of diarrhea, a service included in iCCM, doubled over this period. HEWs made health services more accessible to rural and pastoralist communities, which account for over 80% of the population, with previously low access, a contextual factor that had been a barrier to high coverage of interventions.

CONCLUSIONS

Leveraging the HEP as a platform for service delivery allowed Ethiopia to successfully introduce and scale existing and new EBIs nationally, improving feasibility and reach of introduction and scale-up of interventions. Additional efforts are required to reduce the equity gap in coverage of EBIs including PCV-10 and iCCM among pastoralist and rural communities. As other countries continue to work towards reducing U5M, Ethiopia's experience provides important lessons in effectively delivering key EBIs in the presence of challenging contextual factors.

High prevalence of zero-dose children in underserved and special setting populations in Ethiopia using a generalize estimating equation and concentration index analysis

BACKGROUND

Globally, according to the World Health Organization (WHO) 2023 report, more than 14.3 million children in low- and middle-income countries, primarily in Africa and South-East Asia, are not receiving any vaccinations. Ethiopia is one of the top ten countries contributing to the global number of zero-dose children.

OBJECTIVE

To estimate the prevalence of zero-dose children and associated factors in underserved populations of Ethiopia.

METHODS

A cross-sectional vaccine coverage survey was conducted in June 2022. The study participants were mothers of children aged 12-35 months. Data were collected using the CommCare application system and later analysed using Stata version 17. Vaccination coverage was estimated using a weighted analysis approach. A generalized estimating equation model was fitted to determine the predictors of zero-dose children. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value of 0.05 or less was considered statistically significant.

RESULTS

The overall prevalence of zero-dose children in the study settings was 33.7% (95% CI: 34.9%, 75.7%). Developing and pastoralist regions, internally displaced peoples, newly formed regions, and conflict-affected areas had the highest prevalence of zero-dose children. Wealth index (poorest [AOR = 2.78; 95% CI: 1.70, 4.53], poorer [AOR = 1.96; 95% CI: 1.02, 3.77]), single marital status [AOR = 2.4; 95% CI: 1.7, 3.3], and maternal age (15-24 years) [AOR = 1.2; 95% CI: 1.1, 1.3] were identified as key determinant factors of zero-dose children in the study settings. Additional factors included fewer than four Antenatal care visits (ANC) [AOR = 1.3; 95% CI: 1.2, 1.4], not receiving Postnatal Care (PNC) services [AOR = 2.1; 95% CI: 1.5, 3.0], unavailability of health facilities within the village [AOR = 3.7; 95% CI: 2.6, 5.4], women-headed household [AOR = 1.3; 95% CI:1.02, 1.7], low gender empowerment [AOR = 1.6; 95% CI: 1.3, 2.1], and medium gender empowerment [AOR = 1.7; 95% CI: 1.2, 2.5].

CONCLUSION

In the study settings, the prevalence of zero-dose children is very high. Poor economic status, disempowerment of women, being unmarried, young maternal age, and underutilizing antenatal or post-natal services are the important predictors. Therefore, it is recommended to target tailored integrated and context-specific service delivery approach. Moreover, extend immunization sessions opening hours during the evening/weekend in the city administrations to meet parents' needs.

In-depth reasons for the high proportion of zero-dose children in underserved populations of Ethiopia: Results from a qualitative study

Increasing attention is being given to reach children who fail to receive routine vaccinations, commonly designated as zero-dose children. A comprehensive understanding of the supply- and demand-side barriers is essential to inform zero-dose strategies in high-burden countries and achieve global immunization goals. This qualitative study aimed to identify the barriers for reaching zero-dose and under-immunized children and what and explore gender affects access to vaccination services for children in Ethiopia. Data was collected between March-June 2022 using key informant interviews and focus group discussions with participants in underserved settings. The high proportion of zero-dose children was correlated with inadequate information being provided by health workers, irregularities in service provision, suboptimal staff motivation, high staff turnover, closure and inaccessibility of health facilities, lack of functional health posts, service provision limited to selected days or hours, and gender norms viewing females as responsible for childcare. Demand-side barriers included religious beliefs, cultural norms, fear of vaccine side effects, and lack of awareness and sustained interventions. Recommendations to increase vaccination coverage include strengthening health systems such as services integration, human resources capacity building, increasing incentives for health staff, integrating vaccination services, bolstering the EPI budget especially from the government side, and supporting reliable outreach and static immunization services. Additionally, immunization policy should be revised to include gender considerations including male engagement strategies to improve uptake of immunization services.

Investing in school systems: conceptualising returns on investment across the health, education and social protection sectors

Public policies often aim to improve welfare, economic injustice and reduce inequality, particularly in the social protection, labour, health and education sectors. While these policies frequently operate in silos, the education sphere can operate as a cross-sectoral link. Schools represent a unique locus, with globally hundreds of millions of children attending class every day. A high-profile policy example is school feeding, with over 400 million students worldwide receiving meals in schools. The benefits of harmonising interventions across sectors with a common delivery platform include economies of scale. Moreover, economic evaluation frameworks commonly used to assess policies rarely account for impact across sectors besides their primary intent. For example, school meals are often evaluated for their impact on nutrition, but they also have educational benefits, including increasing attendance and learning and incorporating smallholder farmers into corporate value chains. To address these gaps, we propose the introduction of a comprehensive value-for-money framework for investments toward school systems that acknowledges the return to a common delivery platform-schools-and the multisectoral returns (eg, education, health and nutrition, labour, social protection) emerging from the rollout of school-based programmes. Directly building on benefit-cost analysis methods, this framework could help identify interventions that yield the highest gains in human capital per budget expenditure, with direct implications for finance ministries. Given the detrimental impact of COVID-19 on schoolchildren and human capital, it is urgent to build back stronger and more sustainable welfare systems.

Cost and operational context for national human papillomavirus (HPV) vaccine delivery in six low- and middle-income countries

INTRODUCTION

There are concerns from immunization program planners about high delivery costs for human papillomavirus (HPV) vaccine. Most prior research evaluated costs of HPV vaccine delivery during demonstration projects or at introduction, showing relatively high costs, which may not reflect the costs beyond the pilot or introduction years. This study sought to understand the operational context and estimate delivery costs for HPV vaccine in six national programs, beyond their introduction years.

METHODS

Operational research and microcosting methods were used to retrospectively collect primary data on HPV vaccination program activities in Ethiopia, Guyana, Rwanda, Senegal, Sri Lanka, and Uganda. Data were collected from the national level and a sample of subnational administrative offices and health facilities. Operational data collected were tabulated as percentages and frequencies. Financial costs (monetary outlays) and economic costs (financial plus opportunity costs) were estimated, as was the cost per HPV vaccine dose delivered. Costing was done from the health system perspective and reported in 2019 United States dollars (US$).

RESULTS

Across the study countries, between 53 % and 99 % of HPV vaccination sessions were conducted in schools. Differences were observed in intensity and frequency with which program activities were conducted and resources used. Mean annual economic costs at health facilities in each country ranged from $1,207 to $3,190, while at the national level these ranged from $7,657 to $304,278. Mean annual HPV vaccine doses delivered per health facility in each country ranged from 162 to 761. Mean financial costs per dose per study country ranged from $0.27 to $3.32, while the economic cost per dose ranged from $3.09 to $17.20.

CONCLUSION

HPV vaccine delivery costs were lower than at introduction in some study countries. There were differences in the activities carried out for HPV vaccine delivery and the number of doses delivered, impacting the cost estimates.

Ethiopia National Food and Nutrition Survey to inform the Ethiopian National Food and Nutrition Strategy: a study protocol

INTRODUCTION

Ethiopia has made significant progress in reducing malnutrition in the past two decades. Despite such improvements, a substantial segment of the country's population remains chronically undernourished and suffers from micronutrient deficiencies and from increasing diet-related non-communicable diseases such as diabetes, hypertension and cancer. This survey aims to assess anthropometric status, dietary intake and micronutrient status of Ethiopian children, women and adolescent girls. The study will also assess coverage of direct and indirect nutrition-related interventions and map agricultural soil nutrients. The survey will serve as a baseline for the recently developed Ethiopian Food System Transformation Plan and will inform the implementation of the National Food and Nutrition Strategy.

METHODS AND ANALYSIS

As a population-based, cross-sectional survey, the study will collect data from the 10 regions and 2 city administrations of Ethiopia. The study population will be women of reproductive age, children aged 0-59 months, school-aged children and adolescent girls. A total of 16 596 households will be surveyed, allowing the generation of national and regional estimates. A two-stage stratified cluster sampling procedure will be used to select households. In the first stage, 639 enumeration areas (EAs) will be selected using probability-proportional-to-size allocation. In the second stage, 26 eligible households will be selected within each EA using systematic random selection. Primary outcomes include coverage of direct and indirect nutrition interventions, infant and young child feeding (IYCF) practices, food insecurity, dietary intakes, mental health, anthropometric status, micronutrient status and soil nutrient status.

ETHICS AND DISSEMINATION

The protocol was fully reviewed and approved by the Institutional Review Board of the Ethiopian Public Health Institute (protocol no: EPHI-IRB-317-2020). The study is based on voluntary participation and written informed consent is required from study participants. The findings will be disseminated via forums and conferences and will be submitted for publication in peer-reviewed journals.

Effect of COVID-19 Pandemic on Maternal and Child Health Services and Strategies for Effective Service Implementation in Ethiopia

Introduction

The COVID-19 pandemic is a global burden to the Health sector of developing countries. However, the effect of COVID-19 on maternal and child health services is scarce and no evidence was documented in the Ethiopian context. Hence, this particular study aimed to examine the effect of the pAndemic and to identify effective strategies in Ethiopia.

Methods

Both quantitative and qualitative approaches were applied. For the qualitative, 74 study participants were considered. Study participants were selected purposively and interview guide was used to collect data. Finally audio records were transcribed verbatim, coded and analyzed thematically. For the quantitative, data were extracted from the DHIS2 reports to assess the trend over time.

Results

The qualitative findings indicated that the pandemic affected the MNCH services to be inaccessible and low quality. The trend analysis also showed that the COVID-19 has disrupted MNCH services particularly in the first two months Of the pandemic. Health workers also faced a scarcity of personal protective equipment, work overload and shortage Of resources during the pandemic. As a cope up strategy, the Health system at all levels has established a COVID-19 task force supported by a working guideline. There is also a media prevention program, establishment of quarantine at home, resource mobilization, active surveillance, availing extra ambulances and strong follow-up.

Conclusion

Multiple interventions applied to curb the pandemic have lowered MNCH service utilization. The low commitment of health workers, resources shortage and movement restrictions had a an impact on the uptake of MCH services. There should be a balance in resource utilization to COVID and other essential Health services and the government should avail the necessary supplies during the COVID era. Regionally tailored adaptive interventions are also required to improve MNCH service uptake. Extensive media advocacy and HEWs active involvement for community mobilization are also recommended.

Using the WHO safe childbirth checklist to improve essential care delivery as part of the district-wide maternal and newborn health quality improvement initiative, a time series study

Background

Care bundles are a set of three to five evidence-informed practices which, when performed collectively and reliably, may improve health system performance and patient care. To date, many studies conducted to improve the quality of essential birth care practices (EBPs) have focused primarily on provider- level and have fallen short of the predicted impact on care quality, indicating that a systems approach is needed to improve the delivery of reliable quality care.

This study evaluates the effect of integrating the use of the World Health Organization Safe Childbirth Checklist (WHO-SCC) into a district-wide system improvement collaborative program designed to improve and sustain the delivery of EBPs as measured by “clinical bundle” adherence over-time.

Methods

The WHO-SCC was introduced in the context of a district-wide Maternal and Newborn Health (MNH) collaborative quality of care improvement program in four agrarian Ethiopia regions. Three “clinical bundles” were created from the WHO-SCC: On Admission, Before Pushing, and Soon After Birth bundles. The outcome of each bundle was measured using all- or- none adherence. Adherence was assessed monthly by reviewing charts of live births.

A time-series analysis was employed to assess the effectiveness of system-level interventions on clinical bundle adherence. STATA version 13.1 was used to analyze the trend of each bundle adherence overtime.

Autocorrelation was checked to assess if the assumption of independence in observations collected overtime was valid. Prais-Winsten was used to minimize the effect of autocorrelation.

Findings

Quality improvement interventions targeting the three clinical bundles resulted in improved adherence over time across the four MNH collaborative. In Tankua Abergele collaborative (Tigray Region), the overall mean adherence to “On Admission” bundle was 86% with β = 1.39 (95% CI; 0.47–2.32; P <  0.005) on average monthly.

Similarly, the overall mean adherence to the “Before Pushing” bundle in Dugna Fango collaborative; Southern Nations, Nationalities and People’s (SNNP) region was 80% with β = 2.3 (95% CI; 0.89–3.74; P <  0.005) on average monthly.

Conclusion

Using WHO-SCC paired with a system-wide quality improvement approach improved and sustained quality of EBPs delivery. Further studies should be conducted to evaluate the impact on patient-level outcomes.

An innovative intervention to improve respectful maternity care in three Districts in Ethiopia

BACKGROUND

Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions.

METHODS

Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data.

RESULTS

Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations.

CONCLUSION

This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner.

Vitamin A supplementation and estimated number of averted child deaths in Ethiopia: 15 years in practice (2005-2019)

Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all‐cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural–urban residence. VAS has saved between 167,563 to 376,030 child lives (2005–2019), but additional lives (>42,000) could have been saved with a universal coverage (95%). Inconsistent supply of vitamin A capsules, but more importantly, low access to health care, and the limited contact opportunities for children after 24 months may have contributed to the declining VAS coverage. Any changes in target or scale‐up should thus consider these spatial and socioeconomic variations. Increasing the coverage of VAS and closing the equity gap in access to nutrition services is critical. However, with alternative programmes like vitamin A fortification being set‐up, the benefits and safety of VAS need to be closely monitored, particularly in areas where there will be overlap.

Implementing nationwide measles supplemental immunization activities in Ethiopia in the context of COVID-19: process and lessons learnt

The COVID-19 pandemic has disrupted immunization activities in many countries, causing declines in the delivery of routine doses of antigens, and the postponement of scheduled supplemental immunization activities (SIAs). Following the declaration of the pandemic, Ethiopia postponed nationwide follow-up measles preventive vaccination campaign which was scheduled for April 2020. The disruptions to routine services and the postponement of the SIAs increased the risk for measles outbreaks. The national authorities, in consultation with the secretariat of the National COVID-19 Pandemic Prevention and Control Ministerial Coordination Committee, subnational level authorities, technical partner agencies and stakeholders, reviewed the risks for measles outbreaks and decided to implement the nationwide measles SIAs, with strict implementation of COVID prevention measures. The revised micro-plans accommodated the additional human resource and logistics needs for COVID prevention, for which partner resources were mobilized to fill the gaps. The key SIAs preparatory and implementation activities including training, logistics, social mobilization, service delivery and supervision were modified to take into consideration the COVID context. Infection prevention and control supplies were procured and distributed as a package with the bundled vaccines and other supplies. The SIAs were completed in July 2020 and reached 102.8% administrative coverage nationwide, with 78% of the 1123 woredas attaining the target of 95% coverage. The strong commitment of the leadership, the coordination role of the national and regional COVID prevention and control taskforces, the engagement of community leaders, the use of multi-channel communication, the timely availability of additional resources and modification of the service delivery approaches contributed to the success of the SIAs.

Implementing nationwide measles supplemental immunization activities in Ethiopia in the context of COVID-19: process and lessons learnt

The COVID-19 pandemic has disrupted immunization activities in many countries, causing declines in the delivery of routine doses of antigens, and the postponement of scheduled supplemental immunization activities (SIAs). Following the declaration of the pandemic, Ethiopia postponed nationwide follow-up measles preventive vaccination campaign which was scheduled for April 2020. The disruptions to routine services and the postponement of the SIAs increased the risk for measles outbreaks. The national authorities, in consultation with the secretariat of the National COVID-19 Pandemic Prevention and Control Ministerial Coordination Committee, subnational level authorities, technical partner agencies and stakeholders, reviewed the risks for measles outbreaks and decided to implement the nationwide measles SIAs, with strict implementation of COVID prevention measures. The revised micro-plans accommodated the additional human resource and logistics needs for COVID prevention, for which partner resources were mobilized to fill the gaps. The key SIAs preparatory and implementation activities including training, logistics, social mobilization, service delivery and supervision were modified to take into consideration the COVID context. Infection prevention and control supplies were procured and distributed as a package with the bundled vaccines and other supplies. The SIAs were completed in July 2020 and reached 102.8% administrative coverage nationwide, with 78% of the 1123 woredas attaining the target of 95% coverage. The strong commitment of the leadership, the coordination role of the national and regional COVID prevention and control taskforces, the engagement of community leaders, the use of multi-channel communication, the timely availability of additional resources and modification of the service delivery approaches contributed to the success of the SIAs.

What we know and don't know about the immunization program of Ethiopia: a scoping review of the literature

BACKGROUND

There has been significant recent prioritization and investment in the immunization program in Ethiopia. However, coverage rates have stagnated and remained low for many years, suggesting the presence of systemic barriers to implementation. Hence, there is a need to consolidate the existing knowledge, in order to address them and consequently improve program effectiveness.

METHODS

A thorough literature review and Delphi method were used. In this review, we searched Pubmed/Medline, WHO library, Science direct, Cochrane library, Google scholar and Google using different combinations of search strategies. Studies that applied any study design, data collection and analysis methods related to immunization program were included. In the Delphi method, a panel of 28 national and international experts were participated to identify current evidence gaps and set research priorities under the immunization program.

RESULTS

In this review, a total of 55 studies and national documents were included. The review showed that the vaccination coverage ranged from 20.6% in Afar to 91.7% in Amhara region with large inequities related to socio-economic, health service access and knowledge about vaccination across different settings. Only one study reported evidence on timeliness of immunization as 60%. The review revealed that 80% of health facilities provide immunization service nationally while service availability was only 2% in private health facilities. This review indicated that poor vaccine storage, vaccine shortage, service interruptions, poor defaulter tracing, low community engagement and poor documentation were the main barriers for the Expanded Program on Immunization with variations across different regions. Through expert panel of discussion using Delphi method, 10 priority research areas were identified across different domains of the immunization program at national level.

CONCLUSION

We found out that there is substantial knowledge on vaccination coverage, however, there is little evidence on timeliness of vaccination. The existing barriers that affect full immunization coverage also varied from context to context which indicates there is a need to design and implement evidence based locally tailored interventions. This review also indicated evidence gaps with more focus on health system related implementation barriers at lower level and identified further research priorities in the immunization program of Ethiopia.

Is the legal framework by itself enough for successful WHO code implementation? A case study from Ethiopia

Since 2016, Ethiopia has passed several proclamations and directives to regulate the promotion of commercial breastmilk substitute (BMS). Ethiopia's market potential will undoubtedly be the gravitating point for international infant formula companies due to growing urbanization, purchasing power, population, and the relatively low use of BMS to-date. The aim of this review is to assess the strengths and weaknesses of the existing laws, standards, and monitoring documents used to regulate the marketing of BMSs in Ethiopia and make future recommendations. The study findings highlighted that the regulation on marketing are comprehensive and strong to limit the promotion of infant formula. On the other hand, the regulation on marketing of follow-up formulas, complementary foods, and growing-up milk by manufacturers and distributors, media houses, and communication and advertisement agencies are underregulated, especially with regards to the international 69.9 regulation. The monitoring and enforcement of the existing marketing regulations remain limited in the absence of a formal coordination mechanism. Several violations of the national BMS regulations were observed. Forty-one percent of mothers reported observing the BMS advertising and logos were detected in 36% of health facilities assessed. In 100% of cases, the infant formula labels contained violations. As the lead national authority mandated to regulate food safety, the Ethiopian Food and Drug Authority needs to update its regulations related to the marketing of BMS to fill the loopholes and revise the national law in line with the international code of marketing of BMSs to protect breastfeeding.

Introduction of birth dose of hepatitis B virus vaccine to the immunization program in Ethiopia: an economic evaluation

BACKGROUND

Hepatitis B virus (HBV) infection is an important cause of morbidity and mortality with a very high burden in Africa. The risk of developing chronic infection is marked if the infection is acquired perinatally, which is largely preventable through a birth dose of HBV vaccine. We examined the cost-effectiveness of a birth dose of HBV vaccine in a medical setting in Ethiopia.

METHODS

We constructed a decision analytic model with a Markov process to estimate the costs and effects of a birth dose of HBV vaccine (the intervention), compared with current practices in Ethiopia. Current practice is pentavalent vaccination (DPT-HiB-HepB) administered at 6, 10 and 14 weeks after birth. We used disability-adjusted life years (DALYs) averted to quantify the health benefits while the costs of the intervention were expressed in 2018 USD. Analyses were based on Ethiopian epidemiological, demographic and cost data when available; otherwise we used a thorough literature review, in particular for assigning transition probabilities.

RESULTS

In Ethiopia, where the prevalence of HBV among pregnant women is 5%, adding a birth dose of HBV vaccine would present an incremental cost-effectiveness ratio (ICER) of USD 110 per DALY averted. The estimated ICER compares very favorably with a willingness-to-pay level of 0.31 times gross domestic product per capita (about USD 240 in 2018) in Ethiopia. Our ICER estimates were robust over a wide range of epidemiologic, vaccine effectiveness, vaccine coverage and cost parameter inputs.

CONCLUSIONS

Based on our cost-effectiveness findings, introducing a birth dose of HBV vaccine in Ethiopia would likely be highly cost-effective. Such evidence could help guide policymakers in considering including HBV vaccine into Ethiopia's essential health services package.

Incidence and correlates of low birth weight at a referral hospital in Northwest Ethiopia

BACKGROUND

Weight at birth is a good indicator of the newborn's chances for survival, growth, long-term health and psychosocial development. Low birth weight (LBW) babies are significantly at risk of death, contributing to the high perinatal morbidity and mortality in developing countries. Hence, this study aims to assess the incidence and associated factors of low birth weight (LBW) in Gondar University Hospital deliveries.

METHODS

A cross-sectional study, conducted on 305 live births from May 1- July 30, 2010. Information on independent variables was collected from the mothers just before discharge using a structured interview questionnaire. Neonatal weight was measured using standard beam balance. Both interviews and weight measurements were done by two trained midwives. Gestational age was determined by last normal menstrual period and/or ultrasound examinations.

RESULTS

The mean and standard deviations of the birth weights were 2976 ± 476 grams. Incidence of LBW (birth weight <2500 grams) was 17.1% (95%CI 13.3%, 21.6%). LBW was associated with first delivery (AOR=2.85), lack of antenatal care follow up (AOR= 5.68) or infrequent visits and being HIV positive (AOR=3.22). More female newborns were with low birth weight than males though the difference was not significant after controlling for potential confounders in the multivariate analysis.

CONCLUSION

There is a high incidence of LBW. Efforts should to enhance national antenatal care utilization in general, and particularly in Gondar, should be encouraged as its absence is closely associated with LBW.