Objective To describe the development, implementation and initial outcomes of a national quality improvement (QI) intervention in Ethiopia. Design Retrospective descriptive study of initial prototype phase implementation outcomes. Setting All public facilities in one selected prototype district in each of four agrarian regions. Participants Facility QI teams composed of managers, healthcare workers and health extension workers. Interventions The Ethiopian Federal Ministry of Health (FMoH) and the Institute for Healthcare Improvement co-designed a three-pronged approach to accelerate health system improvement nationally, which included developing a national healthcare quality strategy (NHQS); building QI capability at all health system levels and introducing scalable district MNH QI collaboratives across four regions, involving healthcare providers and managers. Outcome measures Implementation outcomes including fidelity, acceptability, adoption and program effectiveness. Results The NHQS was launched in 2016 and governance structures were established at the federal, regional and sub-regional levels to oversee implementation. A total of 212 federal, regional and woreda managers have been trained in context-specific QI methods, and a national FMoH-owned in-service curriculum has been developed. Four prototype improvement collaboratives have been completed with high fidelity and acceptability. About 102 MNH change ideas were tested and a change package was developed with 83 successfully tested ideas. Conclusion The initial successes observed are attributable to the FMoH’s commitment in implementing the initiative, the active engagement of all stakeholders and the district-wide approach utilized. Challenges included weak data systems and security concerns. The second phase—in 26 district-level collaboratives—is now underway.

Background Various factors may determine the duration of viral shedding (the time from infection to viral RNA-negative conversion or recovery) in COVID-19 patients. Understanding the average duration of recovery and its predictors is crucial in formulating preventive measures and optimizing treatment options. Therefore, evidence showing the duration of recovery from COVID-19 in different contexts and settings is necessary for tailoring appropriate treatment and prevention measures. This study aimed to investigate the average duration and the predictors of recovery from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection among COVID-19 patients. Method A hospital-based prospective cohort study was conducted at Eka Kotebe General Hospital, COVID-19 Isolation and Treatment Center from March 18 to June 27, 2020. The Center was the first hospital designated to manage COVID-19 cases in Ethiopia. The study participants were all COVID-19 adult patients who were admitted to the center during the study period. Follow up was done for the participants from the first date of diagnosis to the date of recovery (negative Real-time Reverse Transcriptase Polymerase Chain Reaction (rRT-PCT) test of throat swab). Result A total of 306 COVID-19 cases were followed up to observe the duration of viral clearance by rRT-PCR. Participants’ mean age was 34 years (18–84 years) and 69% were male. The median duration of viral clearance from each participant’s body was 19 days, but the range was wide: 2 to 71 days. Cough followed by headache was the leading sign of illness among the 67 symptomatic COVID-19 patients; and nearly half of those with comorbidities were known cancer and HIV/AIDS patients on clinical follow up. The median duration of recovery from COVID-19 was different for those with and without previous medical conditions or comorbidities. The rate of recovery from SARS-CoV-2 infection was 36% higher in males than in females (p = 0.043, CI: 1.01, 1.85). The rate of recovery was 93% higher in those with at least one comorbidity than in those without any comorbidity. The risk of delayed recovery was not influenced by blood type, BMI and presence of signs or symptoms. The findings showed that study participants without comorbidities recovered more quickly than those with at least one comorbidity. Therefore, isolation and treatment centers should be prepared to manage the delayed stay of patients having comorbidity.

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Background Ethiopia is the second most populous country in Africa, known for its high fertility and low contraceptive use. The magnitude of contraceptive use in the emerging regions of the country is below the national average. However, there is a paucity of evidence regarding the reasons for low contraceptive use in these regions. Therefore, this study aimed to assess contraceptive use and associated factors in the emerging regions of Ethiopia. Methods For the quantitative part, a community based cross-sectional study was conducted among 2891 reproductive age women who were selected by multistage sampling technique. Data were collected face to face using an open data kit software, and STATA version 14 was used for data analysis. Frequencies, percentages, summary measures and tables were used to summarize and present the data. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with contraceptive use, by computing odds ratio with 95% confidence interval. Level of significance was considered at p-value < 0.05. For the qualitative part, phenomenological study was conducted among 252 health care workers and community members who were selected purposely. The data were collected by focused group discussions, in-depth interviews and key informant interviews. The data were audio-recorded in the local languages, and then translated to English verbatim. NVivo version 11 was used to analyze the data through a thematic analysis method. Results The overall contraceptive prevalence rate was 22.2%; with 11.7, 38.6, 25.5 and 8.8% for Afar, Benshangul Gumuz, Gambela and Somali Regions, respectively. Age, religion, education, marital status, family size, ideal children, knowledge and attitude were significantly associated with contraceptive use. Additionally, the qualitative study identified three themes as barriers to contraceptive use: individual, health care system and sociocultural factors. Conclusions Contraceptive prevalence rate was low in this study compared to the national average. Age, religion, education, marital status, family size, ideal children, knowledge and attitude were significantly associated with contraceptive use. From the qualitative aspect, individual, health care system and sociocultural factors were identified as barriers to contraceptive use. Therefore, the emerging regions of Ethiopia need special focus in increasing contraceptive use through behavioral influence/change.

Objective To estimate the use of hospitals for four essential primary care services offered in health centres in low- and middle-income countries and to explore differences in quality between hospitals and health centres. Methods We extracted data from all demographic and health surveys conducted since 2010 on the type of facilities used for obtaining contraceptives, routine antenatal care and care for minor childhood diarrhoea and cough or fever. Using mixed-effects logistic regression models we assessed associations between hospital use and individual and country-level covariates. We assessed competence of care based on the receipt of essential clinical actions during visits. We also analysed three indicators of user experience from countries with available service provision assessment survey data. Findings On average across 56 countries, public hospitals were used as the sole source of care by 16.9% of 126 012 women who obtained contraceptives, 23.1% of 418 236 women who received routine antenatal care, 19.9% of 47 677 children with diarrhoea and 18.5% of 82 082 children with fever or cough. Hospital use was more common in richer countries with higher expenditures on health per capita and among urban residents and wealthier, better-educated women. Antenatal care quality was higher in hospitals in 44 countries. In a subset of eight countries, people using hospitals tended to spend more, report more problems and be somewhat less satisfied with the care received. Conclusion As countries work towards achieving ambitious health goals, they will need to assess care quality and user preferences to deliver effective primary care services that people want to use.

Background Several studies have reported inadequate levels of quality of care in the Ethiopian health system. Facility characteristics associated with better quality remain unclear. Understanding associations between patient volumes and quality of care could help organize service delivery and potentially improve patient outcomes. Methods Using data from the routine health management information system (HMIS) and the 2014 Ethiopian Service Provision Assessment survey + we assessed associations between daily total outpatient volumes and quality of services. Quality of care at the facility level was estimated as the average of five measures of provider knowledge (clinical vignettes on malaria and tuberculosis) and competence (observations of family planning, antenatal care and sick child care consultations). We used linear regression models adjusted for several facility-level confounders and region fixed effects with log-transformed patient volume fitted as a linear spline. We repeated analyses for the association between volume of antenatal care visits and quality. Results Our analysis included 424 facilities including 270 health centers, 45 primary hospitals and 109 general hospitals in Ethiopia. Quality was low across all facilities ranging from only 18 to 56% with a mean score of 38%. Outpatient volume varied from less than one patient per day to 581. We found a small but statistically significant association between volume and quality which appeared non-linear, with an inverted U-shape. Among facilities seeing less than 90.6 outpatients per day, quality increased with greater patient volumes. Among facilities seeing 90.6 or more outpatients per day, quality decreased with greater patient volumes. We found a similar association between volume and quality of antenatal care visits. Conclusions Health care utilization and quality must be improved throughout the health system in Ethiopia. Our results are suggestive of a potential U-shape association between volume and quality of primary care services. Understanding the links between volume of patients and quality of care may provide insights for organizing service delivery in Ethiopia and similar contexts.

Health management information systems (HMIS) are a crucial source of timely health statistics and have the potential to improve reporting in low-income countries. However, concerns about data quality have hampered their widespread adoption in research and policy decisions. This article presents results from a data verification study undertaken to gain insights into the quality of HMIS data in Ethiopia. We also provide recommendations for working with HMIS data for research and policy translation. We linked the HMIS to the 2016 Emergency Obstetric and Newborn Care Assessment, a national census of all health facilities that provided maternal and newborn health services in Ethiopia. We compared the number of visits for deliveries and caesarean sections (C-sections) reported in the HMIS in 2015 (January–December) to those found in source documents (paper-based labour and delivery and operating theatre registers) in 2425 facilities across Ethiopia. We found that two-thirds of facilities had ‘good’ HMIS reporting for deliveries (defined as reporting within 10% of source documents) and half had ‘very good’ reporting (within 5% of source documents). Results were similar for reporting on C-section deliveries. We found that good reporting was more common in urban areas (OR: 1.30, 95% CI 1.06 to 1.59), public facilities (OR: 2.95, 95% CI 1.38 to 6.29) and in hospitals compared with health centres (OR: 1.71, 95% CI 1.13 to 2.61). Facilities in the Somali and Afar regions had the lowest odds of good reporting compared with Addis Ababa and were more likely to over-report deliveries in the HMIS. Further work remains to address remaining discrepancies in the Ethiopian HMIS. Nonetheless, our findings corroborate previous data verification exercises in Ethiopia and support greater use and uptake of HMIS data for research and policy decisions (particularly, greater use of HMIS data elements (eg, absolute number of services provided each month) rather than coverage indicators). Increased use of these data, combined with feedback mechanisms, is necessary to maintain data quality.

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.