FEDERAL MINISTRY OF HEALTH INTEGRATING ENHANCED OUTREACH STRATEGY (EOS) INTO HEALTH EXTENSION PROGRAMME (HEP) ETHIOPIA A TRANSITIONAL PLAN

Integrating EOS into HEP in Ethiopia, Transitional Plan – Final Report 16-11-10 1

FEDERAL MINISTRY OF HEALTH

INTEGRATING ENHANCED OUTREACH STRATEGY (EOS)

INTO HEALTH EXTENSION PROGRAMME (HEP)

ETHIOPIA

A TRANSITIONAL PLAN

VOLUME I: EOS TO HEP TRANSTIONAL PLAN

(2010/11-2014/15)

FINAL REPORT


TABLE OF CONTENTS

ACRONYMS ............................................................................................................................................................ 3

ACKNOWLEDGEMENT ........................................................................................................................................... 4

1. INTRODUCTION .............................................................................................................................................. 5

1.1 Background to the transitional plan .......................................................................................................... 5 1.2 Objectives and scope of work .................................................................................................................. 6 1.3 Major findings of the assessment and its implication for the transitional plan ......................................... 6 1.4 Roadmap for the Plan .............................................................................................................................. 8

2. OBJECTIVES AND STRATEGIES OF THE TRANSITIONAL PLAN .............................................................. 9

2.1 Objectives ................................................................................................................................................. 9 2.2 Overall strategies .......................................................................................................................................... 10 2.2.1 Urban areas............................................................................................................................................ 14 2.2.2 Pastoralist areas .................................................................................................................................... 15

3. STRENGTHENING THE SUPPORT SYSTEMS FOR HEP .......................................................................... 16

3.1 Planning ................................................................................................................................................. 16 3.2 Training and capacity building of HEW .................................................................................................. 16 3.3 Incentives and motivation ....................................................................................................................... 17 3.4 Communication and community mobilization ......................................................................................... 19 3.5 Strengthening the logistics supply system ............................................................................................. 20 3.6 Supportive supervision ........................................................................................................................... 21 3.7 Reporting and monitoring and evaluation .............................................................................................. 21 3.8 Stakeholder support and coordination ................................................................................................... 22

4. MAIN ACTIVITIES AND THEIR TIME FRAMES ........................................................................................... 24

5. COSTING AND FINANCING ......................................................................................................................... 26

5.1 Costs of strengthening the support systems .......................................................................................... 26 5.2 Financing strategies ............................................................................................................................... 30

ANNEX 1: TRANSITION SCALING UP ASSUMPTIONS BETWEEN ROUTINE AND CHD ................................ 33

ANNEX 2: ESTIMATED BENEFICIARIES IN THE TARGET REGIONS FOR TRANSITION ............................... 34

ANNEX 3: BASIS ASSUMPTIONS OF COSTING ................................................................................................ 35

ANNEX 4: PREPARATORY COST ....................................................................................................................... 36

ANNEX 5: UNIT COST FOR PREPARATORY ACTIVITIES ................................................................................. 37

ANNEX 6: REWARD BEST PERFORMING HEWS, VCHWS AND HEW SUPERVISORS ................................. 37

ANNEX 7: ESTIMATED COST OF VITAMIN A AND DE-WORMING CAPSULES .............................................. 38

ANNEX 8: EOS/EEOS COST BASED ON THE 20 WOREDA STUDY IN AMHARA REGION ............................ 39


ACRONYMS

ANC Antenatal Care

BPR Business Process Re-engineering

CBN Community Based Nutrition

CSA Central Statistical Authority

CHDs Child Health Days

DPs Development Partners

EOS Enhanced Outreach Services

EEOS Enhanced Extended Outreach Services

EFY Ethiopian Fiscal Year

ETB Ethiopian Birr

IEC Information, Education and Communication

FMOH Federal Ministry of Health

GMP Growth Monitoring Programme

HCs Health Centers

HEP health Extension Programme

HEW Health Extension Worker

HMIS Health Management Information System

HPs Health Posts

HSDP Health Sector Development Programme

MUAC Middle Upper Arm Circumference

MDGs Millennium Development Goals

NGO Non-government Organization

NNP National Nutrition Programme

NNS National Nutrition Strategy

OTP Outpatient Therapeutic Programme

PASDEP Programme for Accelerated and Sustained Development to End Poverty

PFSA Pharmaceutical Fund and Supply Agency

PMTCT Prevention of Mother to Child Transmission

TB Tuberculosis

TSF Targeted Supplementary Feeding

VAS Vitamin A supplementation

VCHWs Voluntary Community Health Workers


ACKNOWLEDGEMENT

(To be completed by FMOH)


1. INTRODUCTION

1.1 Background to the transitional plan

The Ethiopian Government has been implementing a Health Sector Development Programme (HSDP)

since 1997 GC1, which promotes decentralization and standardizes the health care at all levels. This

programme has primarily focused on accelerated expansion of primary health care services, of which a key

component is the Health Extension Programme (HEP). HEP has been designed to provide 16 different

packages focusing on promotive, preventive, and selected curative health care services in an accessible

and equitable manner to reach all segments of the population, with special attention to mothers and

children, including immunization, Vitamin A Supplementation (VAS), Oral Rehydration Therapy (ORT),

Family Planning and Antenatal Care. The overall aim of this accelerated programme is to meet the

Millennium Development Goals (MDG).

During its early stages of implementation, it was realized that the HEP will not be able to provide full

coverage of some of the high impact child survival strategies, such as such as Vitamin A supplementation

(VAS in the short to medium term. Hence, the Enhanced Outreach Strategy (EOS) was introduced in 365

drought prone Woredas in 2004. EOS, when introduced, targeted 6,800,000 million children aged 6 to 59

months, for Vitamin A supplementation (VAS), de-worming, screening and referral of malnourished children

and pregnant and lactating women to a Targeted Supplementary Feeding (TSF) Programme. In 2005/06,

the programme was extended to reach all children in the non-EOS Woredas by offering a reduced package

of services through the Expanded Enhanced Outreach programme (EEOS). The EEOS includes only VAS

and de-worming, once every six months. The EOS and EEOS were scaled up at a rapid pace, and

coverage by both services over the past 3 years has remained very high (reached 95% in 2008/2009) and

managed to reach many unreached children.

In the meantime, the FMOH developed a National Nutrition Strategy (NNS) and its five years National

Nutrition Programme (NNP) in 2008. The Strategy brings together the various isolated and uncoordinated

interventions into one comprehensive sector wide approach, led by the government and by one

coordination framework. This has changed the pervasive attitude among stakeholders that „nutrition is

everybody‟s business but nobody‟s responsibility‟ by moving it from cross cutting component of HSDP to

one of the priority programme areas and from thinking nutrition as emergency and food related intervention

to mainstreaming nutrition into health and development programmes. The Programme outlined the core

activities to be implemented for five years and its associated resource requirement. EOS/TSF and its

transition to HEP is one sub component of the service delivery in this programme.

The NNP envisions bringing in the „missing link between the health post and the community‟ through linking

HEWs with voluntary community health workers (CHWs) and model households. The transition of the EOS

into HEP is given high priority. The transition of the EOS/TSF programme to Child Health Days CHDs2 was

piloted in 39 Community Based Nutrition (CBN) Woredas supported by UNICEF in 2009. Some reports

suggest that there are some challenges to “mainstreaming” EOS into routine services. A key concern is the

capacity of the HEWs and the logistics and supply system to maintain the high levels of coverage achieved

through the current delivery models. While there is a general consensus among stakeholders on the need

for a gradual transition, there are also concerns that such a transition may reduce the coverage rates

achieved to date. The experience from other countries such as Kenya demonstrated that this is a valid

1 This document sometimes uses Ethiopian fiscal year (EFY) when specifically mentioned.

2 A child health day is a quarterly scheduled delivery of services through outreach programmes within a Kebele.


concern. The purpose of this transitional plan is therefore to provide evidence based strategies for an

effective transition without seriously affecting the outcomes achieved so far.

This plan is developed by FMOH from February to August 2010 with the leadership of a technical working

group established for this purpose, led by the FMOH. The technical working group was supported by ETC

Crystal and Breakthrough International consultants through the financing provided by Micronutrient Initiative

(MI). The development of this plan has been participatory as evidenced by:

The leadership of the technical working group on the development and review of the tools used in

the assessment of strength and weaknesses of both HEP and EOS/EEOS;

The involvement and inclusion of the views and concerns of HEWs, HEW supervisors, Woreda

health office and Regional health bureaus during the assessment (see volume two of this report);

The inputs and feedbacks provided by development and implementing partners on the draft plan

during a consultative meeting; and

The inputs and provided by the HEWs, Woreda offices and Regional health bureaus on the draft

plan during the consultative meeting.

1.2 Objectives and scope of work The main objective of this assignment is to develop an Operational Plan, acceptable to the MoH that

facilitates the transition from EOS/EEOS to the HEP ensuring and sustaining the current high coverage

levels achieved under EOS/EEOS. The main deliverables were:

a) A Transitional Plan facilitating the transition of the EOS into the HEP formulated, that includes:

o An implementation modality;

o An estimated budget for implementing the plan (based on costs per activity over time with

expected coverage results) and taking into account additional interventions;

o How to use existing recording cards to screen past delivery of EEOS services (e.g. VAS);

o A strategy for integrated short, medium, and long term EEOS logistics and supply;

o How to address motivation of HEWs, other health staff and communities to ensure an

effective transition from EOS to HEP;

b) A Transitional Plan endorsed by the MoH at all levels;

c) National capacity in health planning enhanced.

1.3 Major findings of the assessment and its implication for the transitional plan The strength and weaknesses of HEP and EOS as well as the support systems required to implement these

two programmes in the three contexts (agrarian, urban and pastoralist) are extensively covered in volume II

report. In summary the major findings of the assessment report (Volume II) are:

Agrarian HEP: The HEP has made a significant contribution to the improved health care access and

utilization particularly among children and mothers. This is visible through;(1) an increased number of

households graduated as model households; (2) an increased awareness among the community on

antenatal coverage, Expanded Programme of Immunization (EPI) and Nutrition programmes; (3) an

increased nutritional service coverage including Vitamin A, exclusive breast feeding, Growth Monitoring

Programme (GMP); (4) an increased uptake of Post Natal and Family Planning services and; (5) an

increased coverage of latrine use. The assessment report identified several success factors. These include

strong:

A political commitment;

A shared understanding at all government levels;

A very high investment in ensuring the expansion of the HEP (health posts and HEWs) to bring the

health facilities and health professionals closer to the communities;


A strong attachment of the HEWs to the local political administration, community-based

organizations, NGOs and other community service providers including agricultural extension

agents;

Accumulated work experience of HEWs in the delivery of health services including nutrition,

sanitation, immunization, and family planning services.

If the HEP is to be the driver of health service provision at community level, a range of challenges will need

to be addressed. These challenges include the lack of properly worked out incentive mechanism for HEWs

and their supervisors, lack of career structure and weak supportive supervision. The main conclusion in the

assessment report is that the agrarian HEP is mature enough to implement the transitional plan.

Urban HEP: The urban HEP programme is recently initiated but has a range of attributes that justifies the

initiation of the transitional plan. These include:

Having more qualified HEWs (nurses) that can take up the additional responsibilities with less

investment in the skills building;

Existence of the clinical services offered at the health post and health center that can act as a pull

factor;

Existence of strong Kebele involvement in the health service delivery;

The need to initiate the transition before the „EOS syndrome‟-campaign mentality-sets-in in the new

HEWs;

Easier access for providing better supportive supervision.

The main challenge in the urban HEP is determining a salary level for the HEWs that will fit well with their

academic preparedness. Overall, the main conclusion is that the urban areas have a high potential for

success if the transition of EOS into HEP is initiated.

Pastoralist HEP: the main findings of the assessment report show that the current strength of HEP in the

pastoralist areas may not be able to support the transition of EOS into HEP for many reasons;

The HEP is not yet fully in place;

There are no HPs in over a third of the Kebeles in these regions;

The transition from the former health delivery system to HEP is not yet completed;

The low educational background and short term training (six months) for the HEWs limits their

operational capacity and competence;

The grassroot level Steering /Coordinating mechanism and system has not yet been properly in

place;

The working environment is not conducive for the HEWs to operate as stipulated in the transitional

plan.

EOS: All the stakeholders involved in the implementation of EOS agreed that significant results have been

achieved in terms of child survival strategies. There is also a strong feeling that the expenditure and the

effort put in are not commensurate enough with the achievements. The funds, the mobilized human and

logistics resources and the overall efforts could have been better utilized for the integration of EOS with

other equally essential components of HEP. The current system has not been able to fully utilize the Kebele

structures (development team, women‟s and youth structures). The many different types of volunteers that

exist between CBN and non-CBN Woredas and among programmes remain one of the major challenges.

Support systems: The strength and weaknesses of the support systems (planning, human resources,

supportive supervision, and logistics management, monitoring and reporting) has been presented in Volume


II. The main conclusion in the assessment report is that planning is not integrated into the woreda based

planning. The training of HEW is not integrated and fragmented. There is weak supportive supervision at all

levels of the health system. The HMIS system is not fully operational.

Implications of the main findings for the transitional plan: The lessons drawn from the assessment

report shows that the design and development of the transitional plan has to take into account:

Enhanced mobilization of political commitment at Kebele and Woreda level to ensure the

transitional plan is a priority in their annual plans;

While enhancing the routine services (facility based and house to house), CHDs are required to

increase coverage for outlier villages in and for mocking up operations if and when routine service

delivery is not able to maintain high coverage rates;

The commitment and motivation of HEWs, their supervisors and the volunteers will determine its

success or failure of the transition process;

Voluntary community workers should continue to play a critical role during the CHDs;

Enhancing the primary health care unit with the health center as a technical lead, referral facility

and coordinator of primary health care activities will create the potential for success;

Ensuring the availability of capsules and tablets on a regular basis is critical for the success of the

transitional plan;

Enhancing supporting supervision to mentor and coach HEWs will have a significant impact on the

maintenance of the high coverage rates achieved;

Enhance review of monthly performance of HEWs to help identify challenges and take timely

appropriate actions; and

Strengthening the various supporting systems (planning, supportive supervision, HMIS and

Monitoring and evaluation are necessary if the integration process is to be effective.

1.4 Roadmap for the Plan The second chapter presents the overall objectives and strategies of the transitional plan and its phased

implementation. It also highlights the success factors or pre-conditions for effective implementation. It

clearly highlights where in agrarian, pastoralist and urban contexts should this integration plan should be

implemented and the criteria to be used to select woredas for inclusion. It also presents the three different

service delivery modalities and the strategies for integration. Chapter three presents the various actions and

strategies to be carried out to strengthen the HEP support systems-i.e., planning, training and capacity

building, incentive and motivation, communication and community mobilization, logistics supply system,

support supervision, reporting and monitoring and evaluation. It also outlines the roles of different

stakeholders (government, development partners, and NGOs) in the implementation of this transitional plan.

Chapter four presents the activities and their time frame. Chapter five presents the costing and financing of

the transitional plan. It specifically shows what the assumptions used in estimating the costs, the total costs,

the potential savings that could be made as a result of the transition and sustainability factors considered. It

also presents two choices financing the transitional plan to be negotiated and agreed between the

government and development partners. Finally the various targets, assumptions used are presented in

annexes.


2. OBJECTIVES AND STRATEGIES OF THE TRANSITIONAL PLAN

2.1 Objectives

The objectives of EOS for the HEP transitional plan are to:

a) Maintain the current levels of coverage of Vitamin A and de-worming and reach, as much as

possible, the people that have been unreached by the EOS services so far;

b) Ensure full government ownership of the management and delivery of services by reshaping the

modality of service delivery and by strengthening and operating through the government system;

c) Strengthen synergy and programme effectiveness by enhancing the provision of comprehensive

services at household and facility level including the integration of EOS services into the HEP;

d) Ensure financial sustainability of service delivery and management3.

A two-pronged approach

The EOS interventions will start being integrated into the HEP by the end of the first year of the HSDP IV

(2010/11). This will be done in the agrarian and urban HEP. In the pastoral areas, it will be necessary to

strengthen the HEP programme first before considering the EOS integration into the HEP. The current

modality of service delivery in the pastoralist areas should therefore continue during the HSDP IV.

The transitional plan aims at maintaining the current (high) level of coverage through the routine and CHD

modes of delivery. The services that are going to be transited through this transitional plan are vitamin A

supplementation, de-worming, nutritional screening and the health aspect of TSF. This transitional plan

targets to increase the routine mode of these services gradually. As is shown below, this will be achieved by

better planning, monitoring and performance based recognition by shifting the EOS interventions moving

from the CHD modality to the HEP routine services. This approach is visible in figure 1.

Figure 1: The percentage of EOS beneficiaries addresses by the two transitional modality over the

years

3 The Government needs to diversify financing sources (development partners, foundations, private sector, NGOs, etc)

including treasury and local sources for the procurement of the commodities. In addition to salaries and infrastructure development, the government has started investing on child health commodities by the mobilization of „resources to cover the cost of vaccines, for BCG, TT, and 55 % of OPV and injectable material for traditional vaccines for 2009”

3.

This commitment should be expanded to EOS and CHDs targeted services in the long terms, with particular focus in reaching the unreached children


2.2 Overall strategies

The nutrition programme has become one of the main components of the HSDP IV design. This is clearly a

shift from where nutrition was treated as a cross cutting agenda. With this improved prioritization, the EOS

activities can graduate from a vertical and micro-planning driven activity to an intervention that is budgeted

for and which is integrated into the annual planning process whereby an additional budget is allocated not

only by partners but also through the government system. The strategies used should ensure sustainability

and increase equity among Regions and Woredas.

Phased implementation

As shown in volume II of the report and in the preceding section, the strength of the HEP varies from

Region to Region. A universal transition of the EOS into the agrarian HEP areas may therefore not be

feasible. The Regions with a high HEP performance can initiate the transition process immediately. The

agrarian HEP in Tigray, Amhara, Oromia and SNNPR should therefore immediately initiate the transition

process. Some of the Woredas in Benishangul could also be considered for transition.

Although the urban HEP has recently been introduced and is not yet fully in place, the transition process

could be initiated immediately before starting the implementation of EOS services with the current

modalities. This will be feasible given the higher level HEW skills and the logistical advantages in these

areas.

Although a few high performing Woredas in the pastoralist HEP can still be considered for transition, most

of the Woredas should initiate the transition process only once the HEP is adequately strengthened and will

become functional.

In general, for the Woredas to be included in the transition process it is recommended to be selected as so

called „Transition Triggers‟. The following indicators show the preparedness of these Woredas to implement

the transitional plan without a significant reduction in the coverage rates. These selection criteria need to be

set in the context of each Regional state. The section criteria indicators are:

Readiness and commitment of the Woreda officials;

Woredas where HEWs who implemented/actively participated in EOS or EEOS are available;

Woredas with a substantial number of graduated model families;

Role model Woredas in achieving high HEP targets, mainly EPI coverage;

Woredas with active vCHWs; and

Woredas with more functional supervisors.

Pre-conditions for a successful integration

The actual transitioning of the EOS interventions into the HEP will be initiated in the second year of the

HSDP IV as the first year will be used for the preparatory activities of the transitional plan. The main

preparatory activities that need to be in place to ensure a smooth implementation of the transition are:

Endorsement of the transitional plan and taking the policy decisions and actions required to start

the transition process by the FMOH;

Defining the roles and responsibilities of health sector players at all levels;

Mobilize the necessary resources to implement the necessary activities of the transition;

Ensuring the mechanism and capacity to ensure the availability of supplies;

Develop an implementation guideline and tools: (activities that need to be carried out should be

defined), training and dissemination of these manuals and guidelines to HEWs, Kebele structures

and Woreda levels;


Strengthening the recording and tracking mechanism to ensure that HEWs have adequate

information on their targeted population and a mechanism to record and track the number of people

accessing the services and the modalities by the modalities reached;

Mobilizing the political leaders, the health managers, the HEWs, HEW supervisors, volunteers and

other local level structures and creating consensus, common understanding and the right mind set

on the need for integration;

Conducting the Integrated Refresher community MNCH training as per the new training module;

Implementing the new career development and the implement the approved increment of

performance based salaries to motivate HEWs;

Strengthen the interface between HEWs, volunteers and development committees and other

Kebele structures.

Implementation

The actual implementation of the transition will be carried out in phases. From all 817 Woredas that are part

of the HSDP IV annual planning process, 228 Woredas are already either implementing or planned to

implement CBN. This leaves 590 potential Woredas for transition.

It is proposed that 286 Woredas will implement the transition in year 2, another 224 Woredas in year 3, 37

Woredas in year 4 and 43 Woredas in year five (see Table 1). The number of beneficiaries of this transition

(children aged 6-59 months and 24-59 months as well as pregnant and lactating women) depends on the

actual Woredas selected for its implementation. The crude estimate of the number of beneficiaries made

based on the CSA 2007 Regional population growth is presented in Annex 2.

Table 1: Number of Woredas to transit by Region

Regions Total

number

of

Woredas

Number

of CBN

Woredas

Woredas

eligible

for

transition

# of Woredas in years of

transition

2 3 4 5 Total

Tigray 46 30 16 10 6 16

Afar 32 0 32 3 5 11 13 32

Amhara 168 62 106 21 53 32 106

Oromia 303 72 231 46 116 69 231

Somali 52 0 52 2 5 15 30 52

Benishangul-

Gumuz

20 0 20 5 10 5 20

SNNPR 157 64 93 19 47 28 93

Gambella 13 0 13 2 5 6 13

Harari 9 0 9 9 9

Diredawa 8 0 8 8 8

Addis Ababa 10 0 10 10 10

Total 818 228 590 135 246 166 43 590

It should be noted that this plan can only be implemented in most pastoralist Woredas once the HEP has

been well established and has become fully functional. This requires the full adaptation of the HEP to the

pastoralist context; deployment of more HEWs to each Kebele to meet the sparsely populated and harsh


environment contexts; training and capacity building of HEWs; strengthening of the Woreda health offices;

strengthening of the supervision mechanism; and the expansion of health posts to the majority of Kebeles.

This will require a specific strategy and sufficient resources.

Implementing mixed approaches to service delivery (Facility based routine, home visit combined

with CHD)

With almost a universal coverage of health posts and a significantly increased number of health centers in

the country since the last three years, it is an opportune moment to consider gradually moving towards

integrating the EOS activities fully into the routine health facility and health extension primary health care

system. An analysis of experiences in other countries showed that strategies which only relied on routine

systems (through the daily operation of the facilities) are not likely to achieve high coverage rates of EOS

services after the initial integration.

The transitional plan will therefore enhance three modes of service delivery to maintain the high coverage

rate:

1. Facility based routine;

2. Routine services provided through HEW house to house visit;

3. Community based routine supported by CHDs.

In the long term, the facility based and house to house service provision modalities or the routine services

will be the main service delivery models. In the short term however, CHDs will be maintained as one of the

modalities within the Kebeles to provide a risk mitigation mechanism if and when coverage rates are not

maintained. This approach coupled with efforts that are aimed at strengthening health infrastructure and

attractiveness of health services, strengthening capacities of the health systems and the availability of

resources, will act as a pull factor for increased community utilization at facility level.

Figure 2: Four pronged approach for integration

Integration strategies

During the transitional plan, the EOS integration strategies will be driven by:

Changing the „mind set‟ of the HEWs, HEW supervisors and Woreda level health managers to

move from a campaign mode to routine services. The EOS interventions in both the agrarian and

urban contexts can and will transition into the HEP when the lower level implementing units take

this as their own routine engagement and when they are mobilized and enabled to do so.

Changes in the mind set of public health professionals/ managers should focus on understanding

VAS as an anti-infection agent and not just as a nutrition intervention. This understanding need to

be enhanced in order to ensure high coverage rates with a high impact on reducing mortality rates.

Clear communication strategies need to be out in place to ensure that the transition from the „EOS

syndrome‟ towards understanding EOS as a means of income will be made. A vigorous effort will


be made to ensure that the volunteers (vCHWs, health and development committees as well as

youth and women associations in the Kebeles) will support the shift. The Kebele leadership will be

enabled to lead and manage the integration process within the Kebele. Above all, consensus and

common implementation mentality will be cultivated among the political leaders.

The community will be made aware of the modalities of service delivery during the transition

process. This will include changes in scaling up and strengthening health post based routine

services: implementation of regular service provision programmes as is the case for EPI and family

planning services.

Scaling up and strengthening the house to house provision of services by HEWs and vCHWs.

Scaling up CHDs in every quarter to each Gott as stipulated in the CBN programme. The

distribution of VAS to individual children should take place every six month. CHDs will continue to

support the delivery of child survival service packages by being fully integrated into the HEP as a

specific intervention. The integration will be owned and led by the public sector and implemented

through the HEP.

In order to ensure that the required supplies and vaccines reach the HEWs at the right time, the

months of the CHDs will need to be fixed at the National level so that a clear time table to deliver

these items on time is developed and implemented. Each Woreda and health facilities can then

plan and implement its child health week any time within that month. The HEWs will use the current

EOS outreach sites for CHDs. If necessary the HEWs could carry out mapping of possible sites.

There is no need to carry out such detailed mapping of sites every time that the CHDS are

organized. Each HEW with support from the vCHW will be in charge for one outreach site that will

be open for at least half day depending on the number of eligible children, lactating, and pregnant

women.

Ensure commodity security: EOS related public health commodities will be made available at the

right time, amount and place for routine services and their financing will be diversified. Government

in the long run will take over the financing of these commodities.

The urban areas outside Addis Ababa and Diredawa will implement the routine services primarily through

the house to house services as the HEWs are serving 500 HHs living in close proximity. In this case CHDs

do not seem the most appropriate modality.

The main activities to be carried out are:

Provide appropriate initial and on the job training for HEWs, and vCHWs on how to develop and

integrate EOS into the HEWs and Kebele plan;

Sensitize the Kebele administration (chairman and manager) on the importance of EOS service and

ensure their buy-in for inclusion of these services in the Kebele plan;

Map out Kebele and Gotts showing the areas where the unreached children live and reach

consensus on how to reach them;

Strengthen the enhanced outreach services, including CHDs to Gotts. Continue the CHDs with

improved coordination with other primary health activities. Child focused services, including EOS

services that require quarterly service provisions will be defined and implemented;

Enhance HEW household visits;

Strengthen the quality of services at the health post level and make it a pull factor for the health

facility routine;

Ensure that standards for HPs, HEWs and supervisors are met; the 1:2500 ratio between the

HEWs and population will be maintained;

Conduct strong and pro-active follow up: 1 supervisor with 10 HEWs are achieved; transport

mechanisms for supervisors are made available; running and maintenance costs for the transport is


available at Woreda level; ensure that all the necessary reporting format and registers are

available;

Ensure all the necessary inputs are available (Ensure availability and sustainability of Vitamin A

supplementation, albendazol, (Salter scale, weighing baskets, MAUC and measuring tape etc);

HEWs will be supported by vCHWs during CHDs. Efforts will be made to ensure that 30-50

households are coordinated by a vCHWs. vCHWs will be trained and supported to contribute

effectively. Their role in strengthening the routine services will be explored and recommended

actions will be taken to this end.

Success factors for the integration process: The integration of the EOS into the HEP is not only

technically feasible but is also an important means of ensuring sustained delivery of child survival

interventions in the future. Several additional measures should be taken (within and beyond the health

sector) to guarantee the success of integration. In this respect, the stakeholders identified the following

strategies to maintain high coverage:

Common understanding and creating consensus on the platform for integration among all levels in

the health system is critical. The intended results of integration process will not be achieved without

mobilizing and aligning the interests and capacities of all stakeholders (National, Regional,

Woreda). The objectives and strategies of the transition should be discussed and agreed upon

among the health staff at Woreda level; mobilizing political support at all levels (Woreda, Kebele,

community) for the implementation determines the success of the transition process;

The responsibility for driving the integration process (to plan, organize and execute the transitional

plan and by so doing to increase local ownership) should rest at Woreda level. Without a full

commitment and support of this level, the plan will not be effective. Thus, the integration of EOS will

be one of the Woreda performance indicators to ensure high commitment;

Address some of the career development and motivational issues of HEWs and recognize the

contributions of voluntary community health workers;

Scaling up of the house to house routine service can only be effective when the family folders are

fully functional and when the HEW has full information on the list of under-five children that require

vitamin A and de-worming services. The scaling up and implementation of family folders will be

enhanced in these integrating regions.

The coverage rates of services delivered through EOS and CBN have not yet reached more than a million

targeted children so far. These children could be living in geographically isolated areas not reachable

through the HEP and are likely to be vulnerable segment of the population. Reaching these children is of

paramount importance but could cost as much as three times of the current cost (WB, 2010). It is necessary

to support innovative approaches to reach them. Activities to be undertaken include:

Mapping of the areas that cannot be reached through the routine services by HEWs;

Developing and implementing strategies (CHDs) to reach these “difficult to reach” children in the

short and medium terms and identify the barriers to reach the underserved population through

routine services and envisage appropriate strategies;

Coordinating health partners working on health emergency and explore options and modalities for

them to assist in reaching these underserved children; and

Reaching the population through CHDs or other safety net options.

2.2.1 Urban areas

The urban areas do have better equipped health facilities at health post and health center levels.

Furthermore, the HEWs are being trained for deployment. They are not yet used to the campaign mode of

EOS service delivery. The urban HEWs also will work with about 500-600 households living in a closer


environment. As a consequence the HEW will be familiar with the community members and with the people

who require EOS services including vitamin A supplementation. In this regard, the strategies for integration

therefore are:

Initiate the transition immediately in urban areas. It is not necessary to initiate EOS type of service

delivery with the new HEWs in the urban areas. Once started it will be followed by interventions

related to changing the mind set. The regions of the urban HEP (Addis Ababa and Dire Dawa) are

easy to manage and could “show case” the transition if immediate actions are take to train the

HEWs on how to integrate EOS services in their annual plan;

Ensure that, as part of each HEW plan, EOS services are included with clear targets and strategies

of meeting this in the coming years; and

Develop a data collecting instrument for the HEWs to collect and report on their status of

implementation.

2.2.2 Pastoralist areas

The pastoralist HEP, as presented in the preceding sections, remains in transition and have not matured

enough to be a vehicle for integration. While the transition of EOS will be a long term aim, this will be

evolving as the HEP is well strengthened and contextualized with the pastoralist community needs and

prevailing condition and gradually built up in line with the overall socio-economic development and way of

life.

The main focus in the short and medium terms therefore should focus on strengthening the HEP while

continuing the EOS/EEOS as it is and strengthening the mobile forms of outreach, both vehicle and camel

driven. Specifically, the following actions will help strengthen the HEP in the short term:

Strengthen and upgrade the existing HPs to a minimum functionally acceptable standard/level;

Complete the coverage of the HEP to all Kebeles by opening new sites and assigning HEWs;

Revisit the selection criteria/process and training content of HEWs and calibrate in view of the tasks

ahead;

Strengthen the support system to HEP(mainly the capacity of Woreda HO);

Upgrade the competence/capacity of the HEWs through in-service training and experience sharing

visits;

Review and modify the EOS packages to come out with something congenial to a pastoralist setting

in general and specifically to their varied traditions and ethos;

Continue with the EOS (modified) as campaign and increase the role and participation of the HEWs

in all aspects of the campaign and check them out in the process;

Expand the EOS coverage to the unreached sites;

Orient and prepare the newly graduates before their assignment; and

Initiate the CHD in selected HPs.

In the medium term (three years) after ensuring the strengthened HEP is in place, consider piloting as is

being done in the CBN Woredas. In this period the following action could be considered:

Expand the CHD into additional selected Kebeles;

Evaluate the process and expedite the transitional process.


3. STRENGTHENING THE SUPPORT SYSTEMS FOR HEP

3.1 Planning

The annual planning process (at different levels) will be used as a main vehicle for the planning of the

integration process. This process will be informed by the strength of the Micro Planning Template (MPT).

The algorithms of the EOS tools shall be reviewed and adapted to other programmes and will be integrated

into the annual planning process. There will not be separate planning processes for CHDs. In this regard:

The CHDs /HEP should be part of the Annual National and Regional Health Plans, Woreda Based,

Kebele and HEW health plans. The amount of Vitamin A supplements and De-worming tablet

requirements will be estimated as part of this planning process;

In collaboration with the RHBs and development partners and as part of their annual Woreda based

planning process, Woreda health offices need to develop detailed integration implementation plans

that capture the target population, training required, forecast commodities and estimated financial

support to strengthen the system;

In the Woredas where the transition has taken place and planned to take place, all EOS/EEOS

partners are required to provide financial and logistic support to the Woreda planning exercises and

their consecutive execution;

To facilitate the implementation of the integration process at Kebele level, the Woreda plan should

be supported by micro planning developed and submitted by Kebeles, which will capture:

o CHD planning will be led by the HEW and the HEW is required to identify community based

organizations (youth associations, women associations, peasant associations, Equb, Idir,

etc.) and other partners that could be useful in gathering health related information, target

population and involve them in this task.

o Prepare a map that depicts the health profile of the Kebele and outreach sites

o Select vCHWs with the Kebele and Woreda authorities using criteria provided in the

guideline.

Prepare a micro-plan for the training, commodity and logistics need;

Ensure that training, financial and material support is provided to strengthen planning capacity at

the Woreda and Kebele levels.

The most important critical factor for the success of integration process will be the adherence to Woreda

based planning process as Woredas are central in leading the administration of the routine, house to house

and enhanced routine health services to targeted beneficiaries. Funding and Woreda based planning

process will be harmonized, as much as possible through:

Advocacy for increased funding at Woreda level for recurrent costs;

Funding through the government system to support the transition process.

3.2 Training and capacity building of HEW

Skill upgrading

As presented in the preceding section, one of the challenges associated with the HEWs has been the lack

of skills and in some cases the competing time allocation of HEWs for trainings given by different NGOs.

Nutrition is included as one of the 16 packages of the HEP. However, the current practices revealed that -

unlike in some other topics- the training content of nutrition was not adequate and had not been provided by

experienced trainers. It has been observed that most of the HEWs were not able to interpret simple

anthropometry (MUAC, Weigh/Height etc) and detect overt manifestations of Severe Acute Malnutrition

(SAM) and Moderate Acute Malnutrition (MAM) (edema, skin and hair changes). To address this problem,

interim (gap filling) training programmes have been designed and have been provided by certain partners


and NGOs (but mainly on ad-hoc basis). As a result, the need for systematic skill upgrading has been on

the agenda for some time now.

Recognizing this challenge, the government has now developed an integrated community Maternal

Newborn and Child Health training to be rolled out to the HEWs. It is reported that the training guidelines

are being printed and will soon be initiated. Nutrition related skills including EOS targeted services are part

and parcel of this skills upgrading programme. One positive aspect of this skill upgrading programmes is

that it targets the HEW skills for maternal, newborn and child health services. This may bring improved

services at the health facility level that could act as booster to maintain high coverage rates of EOS

services.

Orientation will be provided to HEW supervisors to enable them understand the full package of the HEP and

practical skills on coaching, and monitoring will be provided. The transitional plan therefore will take this

government initiative on board as a main mechanism for strengthening the capacity of the HEWs. The

transition should invest on this training together with other sources of funding (those targeting maternal and

other child health services). However, if there are still a few nutrition related skills that are not included,

these will be identified and a-one time training programme will be developed and arranged.

Replacement and Career development for HEWs

The sustainability of the integration EOS/EEOS will greatly depend on the continued supply and

strengthening of the HEP with HEWs as well as ensuring their retention in the system. This requires

estimating the attrition of HEWs and maintaining an adequate number of functional training institutions in

each region. The growth of the population and the possible requirement of a third health extension worker

for Kebeles that serve more than 5000 people also require maintaining these institutions.

Another important issue is the development and implementation of career ladder for HEWs. Some regions

have started rewarding high performing HEW by providing higher learning opportunities: diploma

programme in Oromia and degree programme in Tigray. The government has also designed a

correspondence training to upgrade HEWs to level four4. These experiences need to be reviewed and a

clear career development structure will be developed and put in place within the next three years.

3.3 Incentives and motivation

There is no doubt that incentives play an important role for improving the performance of a system.

Appropriate incentives increase the productivity and performance of service providers and their

organizations. Incentives take many forms. In the case of the HEP, the different stakeholders identified

financial, material, and educational incentives. The amount of salary paid to the HEWs is currently very low.

The HEWs have made repeated requests to the local government to increase their salaries. However, their

requests have not yet received a positive response. Until now, all HEWs are paid uniform salaries within

each Regional state.

There is no doubt however that paying them higher salaries would increase their motivation and would

retain them longer in their job. Incentives in the form of prizes for high-performing workers can also boost

the motivation among the HEWs. There is a good initiative in this respect. HEWs that have greater work

performance are given more priority to get scholarship for further training. Provision of in kind incentives

such as work place materials (e.g. shoes, clothes, hats, umbrellas etc.) is important to motivate HEWs.

Location allowances may also be paid to HEWs to encourage and retain them to work in remote and

environmentally harsh areas. This transitional plan therefore proposes two forms of incentives:

4 Grade four here refers to upgrade them to diploma levels


Box 1: Non financial incentives for vCHWs in 4 regions of Ethiopia Most vCHWs said that they were happy to be selected either because they were chosen by their community as worthy of their role or because they wanted to serve or teach their community regarding health. The main reasons for working as vCHWs primarily stemmed from a desire to serve or benefit their community. The lack of payment for their voluntary work did not reduce their motivation. What seemed to have a particularly adverse impact on the motivation of some vCHWs were (i) failure of the community to accept or implement the health messages; and (ii) community perceptions that they were being paid for their work and that they therefore were primarily motivated by self-interest, and (iii) their exclusion from involvement in campaigns along with their per diem payments turned out to be very discouraging for some vCHWs. The non financial incentives that were found to motivate vCHWs were:

Positive change in the health behavior and status of community members in response to the health messages that vCHWs delivered;

The faith and responsibility placed on them by the community;

The community recognition that inspire them to continue carrying out their work;

Organizing events to recognize their work in front of their community;

Instruction, follow-up, and monitoring provided by HEWs;

Receiving a certificate signifying recognition of the work they have done;

Provision of support by the Kebele administration in facilitating their work including visits by Woreda officials;

Rewarding successful communities that implemented health messages as it would facilitate their work both by inspiring and creating a sense of competition between communities; and

Provision of uniforms and other identifying materials to allow the community to recognize vCHWs.

Source: Amare, Yared. 2009. Non-Financial Incentives for Voluntary Community Health Workers: A Qualitative Study. Working Paper No. 1, The Last Ten Kilometers Project, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia.

Performance related incentives to be measured through annual performance awards for the best

performing HEWs. It is proposed that there will be a National, Regional and Woreda level recognition to

acknowledge best performers. The prizes could be 5,000, 3,000, and 2,000 ETB respectively.

Increase and stratify the salary of

HEW according to performance.

The government is now considering

increasing the salaries of all the civil

service including the HEWs. It is

reported that the increment in salary

will be performance based. Criteria

are being developed to identify HEWs

deserving an increased salary. It is

essential to ensure that the criteria

are applied in a transparent manner

to ensure that the gains made so far

by HEP is not eroded by

implementation problems.

Recognizing vCHWs

Voluntary HEWs are playing a very

critical role in CBN Woredas during

CHDs and clear strategies will be put in

place to ensure their involvement in this

process. This will be done through:

Create the necessary awareness and

mobilizing all the local level structures

(development committee at Gott level)

for each 25-30 HHs where they are

available, youth and women

association, health committees where

they are established)} about the need

for integration and ensure their

support in the implementation

process;

Developing real volunteers through

better communication. vCHWs will

support HEWs without any payment.

All incentive mechanisms deployed by

all programmes will be harmonized to

ensure that there is no conflicting strategy among programmes (some programmes are still rewarding

through monthly payments which may compromise the incentive for other programmes). This will be

clearly communicated to volunteers and to ensure that there is no unnecessary expectations from their

side;

Developing and implementing transparent and measurable criteria to select and reward best performing

volunteers (Kebele leaders, volunteers) at all levels of the health system;

Recruit volunteers from graduated model families and train and deploy as much volunteers as possible

to reduce the amount of time each volunteer spends on the implementation of the transitional plan;


The use of non-financial incentive approaches to improve the performance such as use of visual

identification (badges, t-shirts, and others) will be explored and implemented (see Box 1: for best

examples on non financial incentives in Ethiopia). NGOs engaged in this service could help explore the

various ways of the motivating and rewarding before instituting it to the health sector. VCHWs will be

recognized at all levels of the health system during annual reviews. The recognition of volunteers will

take place on a planned and regular basis as part of the annual review process.

3.4 Communication and community mobilization

Sound communication is one of the key transition strategies to raise the community demand for health and

nutrition services and to generate community support for improving primary health services coverage

including the VAS. Efforts will be made to strengthen the routine and regular HEP‟s methods of

communication that includes one to one meetings with HEWs and, use of demonstration and mass media.

Behavioral Change Communication (BCC) materials (leaflets, posters, video films, flip charts, flash cards

etc) and peer education will also be employed whenever appropriate. In addition to the regular nutrition

focused BCC activities, CHDs require well organized and planned social mobilization. CHD centered social

mobilization will be enhanced to mobilize all eligible children and mothers to come to the CHD outreach

sites a week before the actual CHDs. CHDs need to be supported by volunteers (crowd controllers,

recorder, screener and social mobilizers). The HEWs utilization of the existing social mobilization

mechanisms and the VCHWs and model households in their Kebele will be enhanced. The social

mobilization activities will include:

Making house to house visits

Announcing the CHD package during community meetings

Announcing the dates at the health post and during other outreach activities

Mobilizing leaders to convince the community to get the services

Using the Regional radio programme, wherever available

Hanging posters and banners in the community

To effectuate the transition activities, (from the planning stage to the end), communication activities need to

be considered and budgeted for. To this effect communication/community participation, communication

focal persons will be assigned at all levels in charge of the HEP communication planning, implementing,

monitoring and evaluation. Involvement of Kebeles, local traditional religious leaders, women and youth

groups, teachers associations, NGOs in mobilizing the population for the CHD will be harnessed. Working

through existing local level structures will be encouraged to organize the social mobilization. The

communication strategy should increasingly empower the community by providing; (1) the necessary

information and; (2) enhanced consultation that leads in the end to more community collaboration and in the

long run for community responsibility for demanding and using the services.


3.5 Strengthening the logistics supply system

Successful integration of EOS supplies into the routine commodity management system requires that

commodities and supplies will be available with the right amount and at the right time. In this regard, the

following activities will be carried out during the transition period:

Progress review will be carried out by government and DPs (supporting this transition) on the

Global Fund study looking into the capacity of PFSA. Based on the recommendations, support will

be provided to strengthen the PFSA capacity to ensure that it can take over this responsibility in the

second year. Development partners are required/ expected to support this capacity building

process to ensure that EOS is integrated into the logistic system. The capacity requirements needs

to be reviewed in detail but could include; (1) training of HC staff in commodity management for

Health Posts and; (2) strengthening the Regional/ Woreda capacity to get these supplies reach the

health posts in time.

By the time the capacity of PFSA is assured, the EOS commodity supply system will be integrated

into the government system.

In the first year, the current EOS/EEOS procurement, storage and distribution mechanism will be

used for the CHDs/HEP in order to avoid disruption of providing the VAS through the HEWs.

At the Woreda and Kebele level transportation need to be provided.

Drug storage, stock management and distribution capacity at Woreda/health center as well as at

health posts levels will be strengthened through training and availability of the necessary recording

and reporting tools.

Procurement and storage

Irrespective of the implementation modality at National level, PFSA will procure the annual requirement of

Vitamin A and de-worming tablets according to the quantification done in the annual Woreda based plan.

The EOS supplies don‟t need a separate storage other than pharmaceuticals and the existing storage at all

levels should be utilized.

Distribution

PFSA should distribute adequate amount of supplies to the Regional PFSA hubs two months before the

CHDs or distribution day. The Regional PFSA - in consultation with the RHBs- should take the responsibility

to distribute to the Zones and Woredas one month before the CHDs or distribution days. Woredas should

be responsible for transporting the supplies to the health posts two weeks before the CHD or the distribution

day. During the Regional planning it is necessary to align the timing of CHD or distribution day to the

nearest month of PFSA pharmaceutical supplies distribution cycle. Full integration of the logistics of EOS

supplies into the National logistic system of PFSA may not take place immediately. There is thus a need to

have a phased approach with short and long term EEOS logistics plan until the full integration in

procurement and distribution has been completed.

Short term i.e. during the first year of the transitional plan: UNICEF will continue to procure and

distribute the supplies to the Regional PFSA Hubs. PFSA in collaboration with the RHBs takes the

responsibility to distribute to the Zonal and Woreda level according the suggested time line

mentioned above. The Woreda will then distribute to the health posts. UNICEF and PFSA will

develop a plan for smooth handover of this responsibility process to PFSA during the first year;

During the first year, the review of the capacity of PFSA will be carried out and appropriate

interventions will be supported to strengthen PFSA‟s capacity;

Long term (sustainable) plan: After one year, PFSA will procure and distribute all the required

supplies. PFSA takes the responsibility to integrate the procurement of the supplies in its annual

plan.


3.6 Supportive supervision

Supportive supervision is essential to enhance the quality and quantity of services provided by the HEP and

for the integration of EOS services, including the vitamin A supplementation. Data and information for

continuous improvement of the supportive supervision may come from various sources. Supportive

supervision will collect information not only from health facilities and health service providers but also will

give adequate attention to opinions of different service users. Feedback from service users enables

supervisors to identify gaps and strength of the health service delivery practices at the grass-root level. In

so doing, HEW supervisors can improve/ contribute toward the reliability and quality of data used in their

decision-making and technical support to the HEWs. Several actions will be taken to strengthen support

supervision.

1. Revitalize and strengthen the capacity of HEW supervisors; regions will create budgeted posts for

HEW supervisors. The efforts initiated in Oromia region to reduce the turnover of HEW supervisors

will be reviewed and its success can be replicated in other regions.

2. Provide means of transportation for HEW supervisors: The HEW supervisors will be facilitated with

motorbikes to ensure that they provide adequate support supervision and coaching to HEWs. The

transition plan includes financing a portion of this requirement as it will also benefit from such

efforts. Given that the community based “clean delivery newborn care” and other child health

services are going to be scaled up, the availability, financing and maintenance of motorbikes will be

very critical. While the transitional effort should assist the funding of such a scheme, it will not by

any means be the only one to do it. Therefore, strategies of maintenance and financing will be

developed in the first year of transition.

3. Strengthen routine supervision and coaching for the integration: all supervision efforts should

assess the progress HEWs are making in maintaining the coverage of Vitamin A and the de-

worming through health posts and house to house provisions on regular basis. Supervisors should

critically review the monthly reports submitted to them and provide feedback to the HEWs during

their supervision visits and keep them on the right track. This should be part and parcel of the

supervisory checklist for the HEW supervisors.

4. Strengthening recording and reporting: the capacity and skill of the HEWs for recording and

reporting will be strengthened. The use of the family health folders for recording and tracking of

progress of integration of EOS into the HEP will be enhanced. The recording format at the Kebele

level needs to show the site where the service delivery in question is delivered: at health post, at

home, or at CHD. In other words, it is suggested that the mode of vitamin A supplementation will be

clearly recorded and reported (Vitamin A (health post); vitamin A (house to house) and vitamin A

(CHDs). Progress in the first two modalities will provide an indication on how far the HEW is moving

towards integration.

5. Strengthening provision of the technical support from health centers to HEP and CHDs: The CHDs

cannot be successful without the full technical support of HC as the center of PHCU.

3.7 Reporting and monitoring and evaluation

The success of the Child Health Days depends extensively on the Woredas. Since the capacities for

planning and implementation vary widely among them, it is important to find a way to reward high-

performing Woredas and support low-performing ones. Monitoring will therefore become even more

important during this transition. It is also important to continue to evaluate impact, including of new

interventions. Transport of supplies, which is a key to success, needs to be fully integrated with the routine

system delivering other drugs and medical supplies.

The Health Management Information System (HMIS) will be strengthened to ensure that the necessary

information at all levels of the health system is collected, analyzed, reported and used to informs decision

making. The main action required to ensure such system is available for the integration process are:


Revision of the family folder to include nutrition indicators;

Implementing the family folder to ensure that the HEWs have records on the target population in

their catchment;

Ensure that the HEWs record the services provided to each household member on the family folder

and report on monthly basis on the progress made to cover the EOS targeted services. The HEWs

and health facility reports needs to capture the relevant information. Until the HMIS formats are

revised, it is essential to develop instruments and included it as an addendum for the monthly

report;

Train HEWs and their supervisors on the revised reporting formats during the transition.

The availability of reporting formats, registers and information on the target population shall be improved to

ensure that HEWs have the information and the tools to record and report on their challenges and

successes. Lessons from EPI records and monitoring (EPI Monitoring chart) will be learned. The existing

formats being collected by HEWs for different programmes, NGOs and women associations will be

reviewed and harmonized.

The vertical monitoring system of the EOS/ EEOS will be replaced by the routine health sector performance

monitoring system. In this regard, the following will guide the monitoring process of the transitional plan:

Strengthen the regular reporting system and through it ensure that the Vitamin A supplementation

and de-worming performance achievements are; (1) reported monthly by HEWs; (2) reviewed

monthly by the HEW supervisors; and (3) reported quarterly by the Woreda and Regional levels.

The reporting, as much as possible should identify the level of service provided through routine

systems and the CHDs;

Strengthen the monthly health extension supervisor and HEW review meetings. Both the

supervisory and review checklists will be reviewed and updated to include EOS services. Woreda

level performance review will also be enhanced. The Region will carry out its routine quarterly

reviews and progress of the integration process will be one of the core issues for performance

appraisal;

In order to ensure that the transition to routine services is taking root, performance ranking of

Woredas at Regional level and kebel ranking at the Woreda level will be made public and those

with higher achievements will be acknowledged and recognized;

Post coverage sample survey will be carried out every year to validate the coverage rates collected

through the routine systems and inform decision makers to take relevant actions if coverage rates

are not maintained during this transition period.

3.8 Stakeholder support and coordination

Role of the Government

Role of Government: The government will establish a task force at Woreda and Kebele level to ensure that

the transition process is implemented as per the agreed strategy and time frame. As part of its overall

leadership in planning, administration, implementation and monitoring of the HSDP, FMOH will ensure that

the transitional plan is implemented through a broad-based consultative process. It will also ensure that the

necessary budget is allocated to the transition in accordance with the projected estimates of the transitional

plan. It will also ensure that extra resources mobilized through the SWAp process from various DPs, does

not affect its commitment. Federal, Regional and Woreda levels plans should reflect the EOS transition into

the HEP and all the programmes and projects supported by DPs should be aligned with this annual plan

and the transitional plan. As part of its stewardship functions, the FMOH will take all necessary steps to

harness the collaboration and contribution of the key nutrition partners in the implementation of the

transitional plan. It will also ensure that funds provided for implementation of the transitional plan are


exclusively used for financing the approved activities. It will also encourage and actively support

implementing partners in their involvement planning, implementation and monitoring of the transition

process.

Role of the Development Partners

All partners that support the implementation of the NNP will ensure that all current and proposed support to

this programme is aligned with the programme and transitional plan. They will work their planning and

monitoring process as per the guidelines set in the health harmonization manual. They will work towards,

progressively align their own planning, financing, budgeting, review, monitoring, evaluation, and reporting

processes with those procedures and process established for implementation in the Health Harmonization

Manual (HHM) and MDG performance fund. The DPs will also ensure that support to the programme will

have long term commitment, predictability of resource flow, strategies of financial sustainability, continuity of

implementation and exit strategies. The DPs will work towards synchronizing their support and activities

with the government budget cycle and financial year. They will also provide financial information including

details of procurement and technical assistance provided as part of the annual planning process. They will

work within the coordination mechanisms and structures in order to facilitate the dialogue with government

and in line with the good practice as described in the Paris Declaration on Aid Effectiveness and related

publications. They will adopt the use of government systems as much as possible.

Given that EOS was mainly funded through humanitarian assistance, its transition to HEP may be

accompanied by withdrawal of some of its financiers. It is therefore necessary that Development Partners

put an additional effort to fill such gaps by strengthening the HEP.

Role of the implementing Partners (CSOs/NGOs)

All the participating implementing partners will support the implementation of the transition of EOS into the

HEP as per the transitional plan. Their support should be incorporated in the annual plan at all levels of the

health system. The training programme planned and implemented should follow the recently designed

upgrading programme and will as much as possible reduce the fragmentation of training and transaction

cost associated with it. They will ensure that all their nutrition programmes and plans, irrespective of source

of funding, are consistent with the HSDP IV initiatives and NNP. They will disclose all support being

received or solicited for health activities using an accepted format (including source of funding, amounts,

purpose, duration, geographical area, etc) for their programmes, highlighting funding gaps where

appropriate for inclusion in the sector resource envelope, and the planning processes. They will report

regularly and in a timely manner on financial and technical performance in accordance or consistent with

the government reporting and monitoring systems and formats.


4. MAIN ACTIVITIES AND THEIR TIME FRAMES

Based on the preceding description of activities to be carried out during the transition plan, the following

time line is suggested for the implementation. The activities are framed from 2010/11 to 2014/15. The

preparatory activities are shown in 2010/11 and also in annex 3 while the routine activities are to be carried

out throughout.

Table 2: Activities and their time frames

Themes Activities

2010/11 2011/12 2012/13 2013/14 2014/15

Service delivery

Profiling of EOS target beneficiaries by HEWs

Setting targets agreed by HEWs, HEW supervisor, Kebele administration, and the Woreda health office as part of the annual planning process

Enhance facility based routine services

Enhance the house to house provision of EOS services by HEWs

Map out the hard to reach areas that may not be reached by routine services

Undertake CHDs in within Kebeles

Training

Train HEWs on including EOS services in their plans and reporting once

Train Kebele chair persons and manager on integrating EOS in the Kebele plan once

Train health extension supervisors on including EOS in the their supervision, reporting and review checklist once

Train HEWs on integrated MNCH training

Continue new HEW training to replace attrition in agrarian and urban areas

Incentives and motivation

Develop HEW career development programme

Develop performance review standards

Acknowledge best performing HEWs, VCHWs, HEW supervisors, Kebele and Woreda leaders

Planning

Support HEW carry out profiling their households and indentifying their beneficiaries including EOS services

Revise the HEW planning format to include EOS services


Themes Activities

2010/11 2011/12 2012/13 2013/14 2014/15

Integrate EOS annual plans into HEW, Kebele, Woreda based annual plans

Logistics management

Continue the current system of procurement and distribution of EOS supplies for 2010/11

Review the capacity of PFSA to procuring and distributing EOS supplies and identify the required system

Strengthen PFSA for the transition

Forecast annual Vitamin A and De-worming requirements as part of Woreda based planning process and/or annual commodity quantification exercise

Procure Vit A and de-worming on time

Distribute EOS supplies to HC regularly as part of the overall distribution process

Support supervision

Create a HEW supervisor position within the Woreda health office (scaling up the Oromia experience) to reduce attrition

Review the HEW supervisors checklists

Supplement HMIS by developing monthly report formats for HEWs, health posts and health centers

Support the financing of supportive supervision (fuel and HEW Supervisors’ per diems

Performance monitoring

Define indicators for performance monitoring indicators at Kebele and Woreda levels

Revise the Family folder to include Nutrition indicators

Scale up the recording of services using family folders by HEW and the reporting of service coverage through routine services

Strengthen monthly review at Kebele level

Strengthen quarterly review at Woreda level

Reward best performing Woredas and Kebeles

Financial management Train WOFED officers on financial management


5. COSTING AND FINANCING

5.1 Costs of strengthening the support systems

There are two major categories of costs in EOS/EEOS: programme-specific costs and non-programme

costs, which include personnel and capital costs. Total costs consist of programme-specific, personnel, and

capital costs.

Programme costs (incurred exclusively for the delivery of EOS: the costs of capsules, supplies,

transportation, fuel, and vehicle maintenance, training, Information, Education, and Communication

(IEC), and of social mobilization);

Non programme costs (other costs that cannot be fully attributed to the EOS programme.

Programme specific costs

These are costs incurred exclusively for the delivery of EOS/EEOS: the costs of capsules, supplies,

transportation, fuel, and vehicle maintenance, training, per diem, reporting forms, information, education,

and communication (IEC), and of social mobilization. It also includes personnel time that employees at all

levels of the MOH devote to planning, implementing and supervising the programme, and the value of the

substantial amount of time and other inputs that are donated or provided in-kind by other (especially Kebele

and Woreda level) agencies and individual. Per diems do constitute the major cost of the EOS/EEOS.

According to a recent costing study carried out in Ethiopia, per diems paid are twice the average daily

salary of the health workers. It is also estimated that a health officer will spend about 30 days in a year on

EOS activities and earn as much as three months of salary.

An estimation of programme-specific costs provide important information to the MOH about the resources

required to implement EOS or the transitional plan. This will enable the government to compare the costs of

EOS with other health or nutrition programme and to decide on the programme implementation options for

EOS/EEOS like transitioning of EOS into HEP.

Non programme costs

These are other costs that cannot be fully attributed to the EOS programme: Personnel cost (salary) and

other over head cost of FMOH, UNICEF, vehicles, buildings, large equipment, and computers.

An Activity Based Costing (ABC) combined with an ingredients approach is used to cost EOS and EEOS in

Oromia and Amhara regions of Ethiopia. The assumption was that major activities of EOS/EESO at each

organizational level of the programme will be identified and used as the cost centers for which a unit cost

algorithm was done. Accordingly, eleven activities grouped in five areas were identified, which are:

1. Training: TOT and Training of service providers

2. Meetings: Sensitization meeting at the Woreda and Kebele; organizational and promotional

meetings at the Woreda and Kebele; and Review meeting at Regional, Zonal and Woreda level

3. Supplies: supplies (Vitamin A, de-worming tabs, IEC, scissors etc.) in EOS vs. EEOS and with and

without measles, repacking supplies, supplies transport

4. Implementation /distribution day

5. Other Regional Health bureau and Zonal health bureau


Box 2: Estimated Unit costs for EOS/EEOS

Services A recent study by the World Bank ‘Scaling up Nutrition:

what will it cost? Estimated the cost as follows:

Vitamin A supplementation: $1.2/child of 6-59

months per year

Therapeutic Zinc: $1 per child of 6-59 months per

year

De-worming: $0.25 per round per year per child of

12-59 years, once or twice depending on the

country’s context

Iron folic acid: $2 per pregnant woman

Source: World Bank, 2010, Scaling Up Nutrition: What will it

Cost?

Cost estimates

There are three important approaches to estimate the cost programmes such as EOS/EEOS:

a) Cost estimate by cost category which is the distribution of the total cost by programme specific, and non-

programme (personnel and capital) costs;

b) Average cost per child/beneficiary which shows the affordability of the programme;

c) Cost per averted death which shows the cost effectiveness of the programme that helps decision makers

like the MOH to evaluate whether the resources spent are used efficiently.

The costs vary depending on the type of implementation modality (EOS vs. EEOS) and the number of

services delivered. The source for the following estimates of EOS/EEOS costs is the cost analysis of Child

Health Days in Ethiopia done in 2008.5

Estimates by cost category: The total costs of EOS/EEOS (two rounds) are estimated at

about 10 million USD per year for

Oromia and Amhara (see Annex 8).

The total cost per round if only

programme specific costs are

considered is 0.5 for EEOS, 0.6 for

EOS and 0.6 for both (EEOS+EOS)..

The average cost per Woreda of the

combined programme (EOS/EEOS)

is 13, 367 USD per round.

Distribution day costs constitute

40.5% and supply costs account for

4.46% of the total cost.

Most of the costs (80% of the total

implementation/ distribution day

costs) are comprised of personnel

(i.e. salary), per diem and fuel costs.

The average cost per child per round

if only programme specific costs are

considered is 0.5 USD EEOS without

measles; 0.6 USD for EOS without measles; and 0.6 USD for both (EEOS+EOS) without

measles. If measles vaccine is included the cost for both (EEOS+EOS) increases to 1

USD per child.

Assuming a 23 % reduction in the mortality rate of children (in the age group between 6 and 59 months),

due to Vitamin A and the EOS/EEOS programme cost will be achieved, the cost per death averted is

estimated at about 228 USD per child if total EOS/EEOS costs are considered. It is therefore cost-effective

compared to other primary health care interventions. For example the costs are similar to measles

immunization (243 USD), but 6 to 7 times less than malaria vector control (1411 USD), and 14 times less

than Oral Rehydration Therapy (3,835 USD). There are considerable differences in costing.

5 John L Fiedler and Tesfaye Chuko. The cost of Child Health Days: a case study of Ethiopia‟s Enhanced Outreach

Strategy (EOS) Health Policy and Planning 2008;23:222–233


In order to sustain EOS/EEOS high coverage rates, i.e. at least 90% of the children will need to receive

both Vitamin A and de-worming tablet in one round and 85 % of children will need to receive this in both

rounds.

With the transitional plan and as part of the routine HEP, an average annual cost of 0.5 USD per child for

two rounds is required. This will assist the FMOH to decide which approach to adapt and which budget to

allocate for the new transitional plan. With the new transitional plan - especially once it is fully integrated as

a part of the HEP - , the total cost will decrease and it is expected to be more cost effective.

Table 3: Estimated costs of activities (in USD)

Themes Activities Total Cost

Assumption 2010/11 2011/12 2012/13 2013/14 2014/15 Remark

Service delivery Profiling of EOS target beneficiaries by HEWs

No cost

Setting targets agreed by HEW, HEW supervisor, Kebele administration, and the Woreda health office as part of the annual planning process

No cost

Enhance facility based routine services No cost enhance the house to house provision of EOS services by HEWs

No cost

Map out the hard to reach areas that may not be reached by routine services

No cost

Undertake CHDs in hard to reach areas within Kebeles (operational cost)

386,100 459,000 265,500 265,500 1,376,100

Planning , monitoring and

reporting Training

Train HEW on including EOS services in their plans and reporting

20 USD per training per person

143,000 112,000 40,000 152,000

Train health extension supervisors on including EOS in the their supervision, reporting and review checklist

30 USD per training per sup

42,900 33,600 12,000 45,600

Service delivery Train HEWs on integrated MNCH training 6 days


849,420 665,280 237,600 902,880

Pre service training

Provide training for agrarian and urban HEW to replace attrition

Incentives and motivation

Develop HEW career development programme

Support the financing of career development programme

FMOH has plan and fund

Develop performance review standards Reward best performing HEWs, vCHWs and HEW supervisors

917,600 917,600 917,600 917,600 3,670,400

Planning Support HEW carry out profiling their households and indentifying their beneficiaries including EOS services

No cost

Revise the HEW planning format to include EOS services

No cost

Integrate EOS annual plans into heath extension workers, Kebele, Woreda based annual plans

No cost

Logistics management

Continue the current system of procurement and distribution of EOS supplies for 2010/11

The cost is reflected above

Review the capacity of PFSA for procuring and distributing EOS supplies and identify the required system

No cost

Strengthen PFSA for the transition it utilizes the 7% charge

Cost covered as part of procurement

Forecast annual Vitamin A and De-worming requirements as part of Woreda based planning process and/or annual commodity quantification exercise

No cost

Procure Vit A and de-worming on time Vitamin A capsule in 299,899 307,503 315,308 323,319 331,542 1,277,67


Themes Activities Total Cost

Assumption 2010/11 2011/12 2012/13 2013/14 2014/15 Remark

number 1 MUAC Tape 0.03 USD per MUAC

tape, 50 per Kebele 442 442 442 442 442 1,767

Back bag to carry supplies 0.6 USD per bag, one bag per HEW, 10000 HEW in the target regions

6,000 1,200 1,200 It is a onetime cost

Distribute EOS supplies to HC regularly as part of the overall distribution process

7% of all procurement of supplies

21,444 21,556 22,186 22,663 23,239 89,645

Support supervision

Create a HEW supervisor position within the Woreda health office (scaling up the Oromia experience) to reduce attrition

No cost

Review the HEW supervisors checklists

No cost

Supplement HMIS format by developing monthly report formats for HEW, health posts and health centers reporting

Procure and distribute motor bikes for HEW supervisors

FMOH has already secured funding

Monthly supportive supervision ( fuel) 30 l/supervision/ month and 20% of the integrated supervision cost will be covered by the transition

926,640 1,652,400

1,911,600

1,911,600

6,402,240

Print and distribute integrated supervision checklist

2 USD per Kebele, in the target regions for transition

11,400 25,500 29,500 29,500 95,900

Performance Monitoring

Define indicators for performance monitoring indicators at Kebele and Woreda levels

Scale up the recording of services using family folders by HEW and the reporting of service coverage through routine services

Strengthen monthly review at Kebele level

1-day per diem x 2 USD (VCHW and HEWs), 30 VCHW or model HH per Kebele, 12 review meeting per year

1,287,000

1,377,000

1,062,000

1,062,000

4,788,000

Review meeting cost (25% initial and then decrease progressively

Strengthen quarterly review at Woreda level

3-day per diem x 6 USD (supp and HEWs), 30 HEWs and supp per Woreda, four review meeting per year

154,440 165,240 127,440 127,440 574,560 Review meeting cost (25% initial and then decrease progressively

Strengthen quarterly review at Regional level

the cost will be covered by other sources

Reward best performing Woredas and Kebeles

The calculation has considered the scale up of the transition

189,440 284,160 378,880 426,240 1,278,720

Financial management

Train WOFED officers on financial management

Total Preparatory cost (Annex 4) 1,514,985 112,000 40,000 1,666,985

Total Running cost 4,202,121 5,220,036 5,038,944 5,095,102 19,556,203

Grand Total Cost 1,363,105 5,013,001 5,509,636 5,038,944 5,095,102 20,656,683


Estimated cost savings of integration: one of the objectives of integrating EOS into the HEP is to reduce

the cost of the EOS associated with the campaign mode. We used the EOS costing study done for Oromia

and Amhara (see annex 8) for a comparison with the costing estimate for the transition phase. Accordingly

there is at least a saving of $0.67/per child in the initial year and this saving increases to $0.72 per child in

2014/15. In terms of saving per Woreda, the saving ranges from $5402 in 2004 to $18,098(see table 4. It

should be noted that this cost saving does not include overhead costs of managing and supporting the

EOS/EEOS programme (UNICEF”s and MOH overhead costs).

Table 4: estimated savings from transition (USD)

2010/11 2011/12 2012/13 2013/14 2014/15

Cost per Woreda per

annum

21,332 10,455 8,608 8,636

Cost per child per annum 0.5 0.4 0.4 0.4

Cost per Woreda per

annum saved

5,402 16,279 18,126 18,098

Cost per child per annum

saved

0.67 0.70 0.72 0.72

Sustainability of services: the transitional plan is integrating EOS services into the routine health services.

The plan recommends financing of capacity building and system strengthening efforts during the transition

period. The plan assumes a gradual taking over of government financing and cooperation of other

programmes. The plan has included in its costing structure that:

Government fully finances additional incentive costs of HEW

It finances 25% of the supervision running costs

It finances 25 % of the monitoring costs

There will be a gradual declining share of procurement costs from development partners

The major success factor for ensuring sustainability is the commitment of the government and the openness

of other vertical programmes that use HEP to delivery services to work in an aligned and cooperative

manner.

5.2 Financing strategies

Integration of EOS/EEOS into the HEP also calls for integrating its financing and financial management.

The existing financing and financial management has been carried out outside the government financial

management system and as a result it has not contributed to strengthening the system. The following

options are recommended for financing of the integration process.

Option one: MDG PF

The government and development partners have established a MDG Performance Fund to harmonize and

align - not only their plans but also their financing - to the various underfinanced services. The Fund, since it

uses government systems, will strengthen the health systems and at the same time reduces the transaction

cost (associated with a vertical management). In its design the MDG Fund has four areas of focus: (1) HEP,

(2) maternal and child health, (3) commodities and supplies and (4) strengthening health systems. Even

though neither EOS nor nutrition is mentioned in the design of the MDG Fund, the priorities of this

transitional plans fits well to the eligible areas of the MDG Fund as can be seen in figure 3.


Nutrition can also be included as one of the emerging priorities (left open in each major focus area) if need

arises. Given that the Fund mobilizes resources for underfunded services and specially for strengthening

HEP, it may also be used as a vehicle for mobilizing additional resources that might have been lost when

emergency funding is reduced.

The main challenge though is that the MDG Fund only encourages an un-earmarked resource to be

managed in a flexible manner. In this regard, given the fact that nutrition is underfunded and that its core set

of development partners want this fund to increase, and would like to have an assurance that the nutrition

bound resources are not allocated to other services, there are issues to be looked intoIn other words, the

DPs would like to limit the fungibility (use of resources for other priority areas) of nutrition resources. Until

the transitional process is complete, it may be necessary to consider the fund that comes to support this

integration process be earmarked. The DPs should then discuss the resource allocation decisions during

specific meetings. The current arrangement does not seem to allow earmarking. Decision needs to be

made by FMOH and its core nutrition partners whether MDG fund is the preferred modality.

Figure 3: Eligible services funded through MDG performance Fund

The second important issue regarding the use of MDG Fund as a funding modality related to financial

management. According to the Joint Financing Arrangement that established the MDG performance Fund,

the FMOH will conduct its accounting, recording and reporting functions as well as all other financial

management and internal control procedures in full compliance with the Ethiopian governing financial

legislation, related decrees, standards and guidelines as issued by Ministry of Finance and Economic

Development MOFED. A quarterly MDG Fund Financial and Activity Report will be prepared at the end of

the quarter and indicate the year-to-date advances and expenditures and all remaining balances in the

MDG Fund account. At the end of the financial year, any unspent balances will be carried forward to the

next financial year, in accordance with Article 29.2 of the Financial Administration Proclamation. The

quarterly MDG Fund financial and activity report will include 6-month cash flow statements that guide

contributors to the MDG Performance Fund in their disbursements into the MDG. DPs shall provide regular

information on commitments and disbursements to the MDG Fund in line with the agreed annual cycle. The


first disbursement of the fiscal year the Signatory DPs will normally advance at least an amount sufficient to

meet 50% of the annual eligible expenditures agreed between FMOH and the DPs.

The MDG PF is ring-fenced (limited in its scope) to finance, activities that are going to be carried out at the

central level. This integration on the other hand is going to finance activities mainly implemented at lower

levels of the health system. The fund has only transferred construction related resources to the Regional

levels so far and has not yet started to provide programme running costs. While the integration of EOS into

the HEP could help it initiate this needed step, the necessary financial fiduciary risk issues (disbursement,

accounting, and reporting) need to be defined and sorted out. The GAVI Health System Strengthening

(HSS) experience of providing the Woredas adequate lead time to liquidate their funds, could be replicated

to ensure smooth financing and reporting of lower levels. The financial management particularly at Regional

and Woreda levels is generally run through the Beauro of Finance and Economic Development BOFEDs

and WOFEDs. Every effort will be made to ensure that these institutions are on board and agreed to its

implementation. Training and orientation will be provided to WOFED staff on how to account the funds

transferred through the MDG PF.

While in principle this fund provides the mechanism for more alignment and harmonization among

programmes and development partners, decision has to be made by FMOH and its nutrition partners

whether this is a preferred mode of financing.

Option 2: Channel 2 - managed by the FMOH

The FMOH have a channel two account where programme funds are channeled to and the FMOH transfers

to regions. Most of the development partners (bilateral, multilateral and global health initiatives like the

GAVI and Global Fund) used this channel. There are ample experiences from different projects in this

modality. The major short coming of this channel is that it requires separate reporting and planning process.

Managing the different projects to finance this transition may also complicate the management process.


ANNEX 1: TRANSITION SCALING UP ASSUMPTIONS BETWEEN ROUTINE AND

CHD (LOCAL CAMPAIGN)

2010/11 2011/12 2012/13 2013/14 2014/15

Routine CHD Routine CHD Routine CHD Routine CHD Routine CHD

40% 60% 60% 40% 80% 20% 90% 10% 100% 5%


ANNEX 2: ESTIMATED BENEFICIARIES IN THE TARGET REGIONS FOR TRANSITION

Region Total

Population

Pop growth

rate

Pop 6-59 months

No of

Woreda

2010/11 2011/12 2012/13 2013/14 2014/15

Tigray 4,314,456 2.5 47 724829 742949 761523 780561 800075

Amhara 17,214,056 1.7 138 2847893 2896308 2945545 2995619 3046545

Oromia 27,158,471 2.9 278 4597386 4730710 4867901 5009070 5154333

SNNP 15,042,531 2.9 155 2546400 2620245 2696232 2774423 2854881

Harari 183,344 2.6 1 30860 31663 32486 33331 34197

Addis

Ababa

2,738,248 2.1 10 456521 466108 475896 485890 496093

Dire Dawa 342,827 2.5 1 57595 59035 60511 62023 63574

Total 66,993,933 17 630 11,261,48

4

11,547,018 11,840,094 12,140,91

7

12,449,699

Children of (24-59 months)

Tigray 4,314,456 2.5 466608 478274 490230 502486 515048

Amhara 17,214,056 1.7 1833331 1864498 1896194 1928430 1961213

Oromia 27,158,471 2.9 2959567 3045395 3133711 3224589 3318102

SNNP 15,042,531 2.9 1639245 1686783 1735700 1786035 1837830

Harari 183,344 2.6 19866 20383 20913 21457 22015

Addis

Ababa

2,738,248 2.1 293885 300057 306358 312792 319360

Dire Dawa 342,827 2.5 37077 38004 38954 39928 40926

Total? 7,249,580 7,433,393 7,622,060 7,815,715 8,014,494

Pregnant and lactating women

Tigray 4,314,456 2.5 168976 173200 177530 181968 186518

Amhara 17,214,056 1.7 663915 675202 686680 698354 710226

Oromia 27,158,471 2.9 1071766 1102847 1134829 1167739 1201604

SNNP 15,042,531 2.9 593629 610845 628559 646787 665544

Harari 183,344 2.6 7194 7381 7573 7770 7972

Addis

Ababa

2,738,248 2.1 106426 108661 110943 113273 115652

Dire Dawa 342,827 2.5 13427 13762 14107 14459 14821

Total? 2625333 2691898 2760222 2830351 2902336


ANNEX 3: BASIS ASSUMPTIONS OF COSTING

Undertake CHDs in hard to reach areas within Kebeles (operational cost)

9450 Kebeles in the regions where transitional plan is going to be implemented

1 Supervisor per 5 Kebele (HP)

20 km travel per supervise to conduct supervision during CHD

1 liter of fuel per 8 Km, 0.7 USD per liter

4 round of CHD (local campaigns) within the Kebele

The CHD coverage progressively decreases (60% to 0%) as the routine service takes over

Planning, monitoring and reporting training

For Woreda Coordinators, Kebele chairman, nucleus health center head and 1 Supervisor per 10 HEW

For 2 HEWs per Kebele

Train Kebele chair persons and manager on integrating EOS in the Kebele plan

1-day per diem x20 members x 11USD; 1-day orientation x 1 USD refreshment; 0.5 USD stationeries;

250 USD per Kebele

it considers the scale up of the integrated/transition approach

Train HEW on including EOS services in their plans and reporting

3-day per diem x 6 USD; 1-day training x 0.4 USD refreshments; 0.4 stationeries; 1.5 USD

transportation


50% trained in 2003 and 50% in 2004

Train HEWs on integrated MNCH training 6 days

8-day per diem x 6 USD; 6-day training x 0.4 USD refreshments; 0.4 stationeries; 1.5 USD

transportation


Support the financing of career development program

HEWs sall scale incentive

HEW supervisor, 250 birr per month to motivate them


ANNEX 4: PREPARATORY COST

Orientation workshops on the

integration

Assumptions 2010/11 2011/12 2012/13 Total

Orientation workshop to Federal, and

Regional health bureaus

,1,440 USD per

orientation

1,440 1,440

Orientation meeting with Zonal and

Woreda health offices, Woreda, and

Kebele administration, HEWs, and HEWs

supervisors on the integration

500 USD per

orientation/ Woreda

143,000

112,000

40,000 295,000

Orientation of partners on the integration

to support the process

200 USD per

orientation

6,000 6,000

Logistic planning -

Consultation meeting with PFSA (Federal

and Regional) on the logistic of supplies

1,440 USD per

orientation

1,440 1,440

Training -

Train HEW on including EOS services in

their annual plans and reporting

20 USD per HEW

143,000

112,000

40,000 295,000

Train health extension supervisors on

including EOS in the their supervision,

reporting and review checklist

30 USD per HEW

supervisor

42,900 33,600 12,000 88,500

Train HEW supervisors and HEWs on the

integrated MNCH training 6 days

54 USD

/training/person

849,420

665,280

237,600

1,752,300

Total

1,187,200

922,880

329,600

2,439,680


ANNEX 5: UNIT COST FOR PREPARATORY ACTIVITIES

Orientation Regional, zonal

and federal

Unit Cost Unit Total

Cost

Per diem 14.4 0 0

Refreshment & Stationary 3 30 87

Transport 19 30 577

Hall rent 48 1 48

84.6 712

Woreda Sensitization Unit Cost Unit

Per diem 6.7 30 202

Refreshment & Stationary 1 30 43

Transport 5 30 144

Hall rent 19 1 19

409

ANNEX 6: REWARD BEST PERFORMING HEWS, VCHWS AND HEW SUPERVISORS

Estimated unit costs in ETB

National Level Regional Level Woreda level

Number of HEW supervisors, HEWs, vCHWs

(for each category)

3 3 3

Award unit cost/per awarding

HEW supervisors 2000 2000 1000

HEW 5000 3000 2000

VCHWs 500 3000 200

Woreda leaders 5000 3000 1000

Kebele leaders 2000 2000 1000


ANNEX 7: ESTIMATED COST OF VITAMIN A AND DE-WORMING CAPSULES

Estimated Vitamin A capsule in number and USD

2010/11 USD 2011/12 USD 2012/13 USD 2013/14 USD 2014/15 USD

451858 9037 463155 9263 474733 9495 486602 9732 498767 9975

1775377 35508 1805558 36111 1836253 36725 1867469 37349 1899216 37984

2866010 57320 2949125 58982 3034649 60693 3122654 62453 3213211 64264

1587426 31749 1633461 32669 1680831 33617 1729575 34592 1779733 35595

19238 385 19739 395 20252 405 20778 416 21319 426

284595 5692 290572 5811 296674 5933 302904 6058 309265 6185

35905 718 36802 736 37722 754 38665 773 39632 793

Total 140408 143968 147622 151373 155223

Estimated De-worming tabs and USD

1026539 10265 1052202 10522 1078507 10785 1105470 11055 1133106 11331

4033329 40333 4101896 41019 4171628 41716 4242546 42425 4314669 43147

6511048 65110 6699868 66999 6894164 68942 7094095 70941 7299824 72998

3606339 36063 3710922 37109 3818539 38185 3929277 39293 4043226 40432

43706 437 44842 448 46008 460 47205 472 48432 484

646547 6465 660125 6601 673988 6740 688141 6881 702592 7026

81569 816 83608 836 85698 857 87841 878 90037 900

Total 159491 163535 167685 171946 176319


ANNEX 8: EOS/EEOS COST BASED ON THE 20 WOREDA STUDY IN AMHARA

REGION

The average cost per Woreda of EOS/EEOS is 120 527 Birr (USS$13 367) per round 13367

The average cost per Woreda of EOS/EEOS is 120 527 Birr (USS$13 367) per annum 26734

The EOS’s average cost per Woreda per round is 7% higher than the average cost per

Woreda of the EEOS, 124 500 and 116 800 Birr, respectively (US$13 807 and US$12

953, respectively).

The average cost of EOS/EEOS per child per round 0.57

The average cost of EOS/EEOS per child per annum 1.14

Distribution day cost per region per round

Oromia Amhara Both

7413 4808

7751 3867

964 964

1712 1712

17840 11351 29191

Personnel (salary), Per diem, and fuel cost (89% of the distribution cost) 25980

Personnel (salary), Per diem, and fuel cost per district per round (for 40

Woredas)

649

FEDERAL MINISTRY OF HEALTH INTEGRATING ENHANCED OUTREACH STRATEGY (EOS) INTO HEALTH EXTENSION PROGRAMME (HEP) ETHIOPIA A TRANSITIONAL PLAN

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