Primary Health Care Unit System Bottlenecks Foc

Reform (PHCU-SBFR)

PHCU-SBFR Training ,

August 28, 2024

Adama, Ethiopia
 Outline
• Background • Health post level interventions
• Rationale • Health center-level
• Project designing process interventions
• SCOPE, Approach, • Primary Hospital level
• Goal and Objective interventions
• Working Principles • Woreda Health office
• PRIORITIES AREAS, AND MAJOR • Implementation arrangement
INTERVENTIONS • Monitoring and evaluation
• Annex
 Background
Universal Health Primary Health
Ethiopia
coverage Care
• Everyone • Almeta • PHC- policy
everywhere Declaration priority
• highest attainable • Astana • 1991 Health
standard of Declaration Policy
health • Health Extension
Program
 Rationale
Significant progress in access to healthcare

Gaps in quality, safety, and equity of care

• Rural, pastoralist and semi pastoralist

Not receiving recommended health services

• poor adherence to clinical care guidelines and unavailability of basic drugs, and equipment.

Stagnation of the progress on key indices

• Neonatal mortality
 Rationale- Bottlenecks
Fragmented service delivery
• Within facility
• Among facilities
• programmatic implementation

Low data quality, data use ineffective monitoring and evaluation, and weak link to
improvement mechanisms.
Poor resource mapping, registration, and notification system.

Weak leadership, governance, and accountability

 Project Design Process
Collaborative
• Participatory

Core team
• Preliminary analysis of PHCU landscape
• Technical recommendations

Series of consultative workshops with various stakeholders

• Inputs taken and incorporated into the document

Overall oversight
• Higher officials of MoH
 SCOPE and Approach
National
• All regions
Phases
• Pilot (18 months)
31 woredas and Sub-cities
• 23 rural, 6 urban, and 2 sub-cities
PHCUs
• Primary hospitals, health centers, and health posts including community and
WoHO
 Goal
• Address PHCU system bottlenecks
• Installing innovative interventions
• Foster quality and equity of
essential health services
• Selected 31 woredas/sub-cities
 Objectives
Pilot test new interventions that improve the quality of care
Pilot provided at PHCUs.

Foster institutional practices for an evidence-driven and standard-

Foster based health service delivery system.

Ensure regular, and transparent performance monitoring, feedback,

Ensure and learning mechanisms at PHCUs.

Strengthen multi-sectoral engagement and community ownership

Strengthen in improving access and quality of care
 Working Principles
Innovation and
Competent and Evidence and technology-
accountable Context-based oriented
leadership. decisions. provision of
care.
Safe and Recognize
conducive work success stories Integration
environment. and champions.

Efficiency Result oriented.

PRIORITIES AREAS, AND MAJOR INTERVENTIONS
PRIORITIES AREAS, AND MAJOR INTERVENTIONS

Outline

1.Health post level Priority Area & Major interventions

2.Heal center level Priority Area & major interventions

3.Primary hospital level Priority Area & major interventions

 1.Health post level Priority Area & Major interventions

Priority Area

 Dashboard-based Intensive M&E

 Digitization

 Improving Community Health Through School Health Clubs

Health Post Level Interventions
Dashboard-based Intensive M&E Digitization
• Adapt/adopt a dashboard and
• Fully digitize the health post
monitor the daily performance
services to be paper-free.
of the HEP package Annex
3: Health post-level dashboards • Integrate CBHI membership
• Report the performance of health enrollment, and renewal in the
post to health center weekly. eCHIS.
Annex15 Health Post reporting for
mat
 Health Post Level Interventions

Improving Community Health through school Health clubs,

• Select teachers for school health clubs and assign 1 teacher for each “Goth” or
Village.
• Orient champion teachers about school health clubs and health extension packages.
• Facilitate linkage between teachers, students, and households.
• Monitor the school health club activity weekly via telephone
2.Health Canter level Priority Area & Major interventions
Priority Area
 High-impact leadership and coordination
 Emergency service and Preparedness

 Client-centered care

 Effectiveness of Care and Safety

 Conducive working environment

 Pharmaceuticals and supply

 Improving Community Health through school Health clubs

 Health centre-level interventions

High-impact leadership and coordination

• Establish Health Center SBFR Taskforce with ToR( sample tor For HC,PH,GH)
• Team members will be assigned with an official letter
• Adopt/adapt and Display the SBFR dashboard. (Annex 4 )
• Conduct daily task force meetings with the health center /CEO/PHCU director.
• Should be held before morning meeting /clinical /department Morning sessions (1:30-
2:00 Local time)
Health centre-level interventions…

High-impact leadership and coordination

• Conduct SMT-Lead sudden supervision monthly.

• Review SBFR performance every week
• Link the meeting /review feedback with action (QI, Action plan, and accountability
measures)
• Report SBFR performance to WoHO weekly.
 Health centre-level interventions
Emergency Preparedness

• Emergency Unit arrangement as per the ER standard

• health center regulatory standard
• Standardize emergency cabinet (drugs and supplies).
• At least prioritize ten drugs and five supplies and
• monitor their quantity during the handover time
• Evaluate Emergency room performance using a dashboard every week
including clinical audit findings
 Health centre-level interventions…

Client-centered care
• Early initiation of OPD services before regular beginning time
• (government working hours)
• Implement a block appointment system for chronic OPD and ANC clinics based on patient
flow volume.
• At least morning and afternoon blocks
• Standardize health education materials for common illnesses (chronic illnesses
Hypertension, Diabetes Mellitus, ANC, Child health, family)
Health centre-level interventions…
Client-centered care…

• Standardize and provide appropriate and complete information for individual clients.
• Provide appropriate and complete information

• Adapt/adopt national or regional Health education materials and audio-visuals translated into
different local languages for common conditions (Hypertension, Diabetes Mellitus ),ANC, Child health,
family planning))

• conduct client interviews to assess the health education counseling and information
provision. Annex 8: Client interview checklist
 Health centre-level interventions
Effectiveness of care and safety
• Monitor adherence to Ethiopian Primary Health Care Clinical Guidelines through Regular clinical audits.

• The task force conducts daily clinical audits. Randomly sample 6 charts (2 from ER, two from IPD, and

two from OPD), where 01 should be of either DM or HTN chronic diseases.

• Special emphasis should be given to. 1 correctness of the diagnosis, 2. appropriateness of the investigation 3.

rational use of the drugs 3. appropriateness of the referral.

• Conduct death and complication audits with emphasis on near misses and harm such as Postpartum Hemorrhage,

neonatal asphyxia, maternal mortality, stillbirth, IUFD, and late referral.

• All charts with the incident (complication)

Health centre-level interventions
Conducive working environment
• Avail Gender-based (not scope or profession-based) duty room arrangement with bathroom and hand
washing facility
• Equip duty rooms with furniture, computer, and /or internet access.
• Prepare a cupboard/ locker for all staff to secure all their personal belongings, gowns, and uniforms.

• Ensure 24 hrs. access to water (portable purifier)

• Conduct regular duty room housekeeping service with daily cleaning and linen change
service.
• The number of beds equals 50% of the staff on duty.
 Health centre-level interventions
Diagnostic care/Lab and Imaging

• Establish an audit and monitoring system for five prioritized lab

test reagents and supplies.
• Establish audit and monitoring system for major Imaging
services and conduct a weekly audit.
• urban health centers
Health centre-level interventions
Pharmaceuticals and supply

• Decide on a list of 10 prioritized drugs and Monitor using the

Dashboard.

• Prioritization should consider cost, risk of addiction, and drug

resistance.
Health centre-level interventions

Improving Community Health through school Health clubs

• Monitor the implementation of school health clubs two weekly on-

site.
 2.Primary Hospital level Priority Area & Major interventions

Priority Area
 High-impact leadership and coordination
 Emergency service and Preparedness

 Conducive working environment

 Laboratory and Diagnostic services

 Pharmaceutical services

 Outpatient Service

 Inpatient care

Health Center support and recognition

Primary Hospital Level Interventions
High Impact Leadership and coordination

• Establish Health Hospital SBFR Taskforce with ToR

• Team members will be assigned with an official letter

• Adopt/ adapt the SBFR dashboard(
Annex 5: SBFR monitoring Dashboard for General and Primary Hospitals.)
• Conduct daily CEO/CCO Lead Taskforce meetings

• Should be held before morning meeting /clinical /department Morning sessions (1:30-2:00
Local time)
• Conduct SMT-Lead sudden supervision monthly.

• Conduct a daily clinical audit.

• Take two medical records from each unit. For a sample clinical audit tool, refer to annexes.
Primary Hospital Level Interventions

High Impact Leadership and coordination …

• Conduct Weekly Clinical forum led by CEO/CCO on SBFR performance.

• Display major service areas' performances weekly and make the data accessible to team leaders,

department heads, and CEO/CCO. /Dashboards could be adapted/adopted, Whiteboard/Digital.

• Report SBFR performance to Woreda/zone health department weekly

• Annex 17 General and Primary Hospital Reporting Template

 Primary Hospital Level Interventions
Emergency Care and Readiness

• Standardize the emergency drug cabinet and ensure proper handover in selected service areas
(Emergency, inpatient, central triage).
• A list of emergency drugs and supplies with the minimum quantity to be used should
be standardized; there should be a mechanism for refilling and handing over during each shift.
• Conduct ER performance reviews and have a discussion team forum weekly.
• Implement nursing care process for all kept patients.
• Define “Kept cases” for emergency patients contextually.
 Primary Hospital Level Interventions
Conducive working environment
• Avail Gender-based (not scope or profession-based) duty room arrangement with bathroom and
hand washing facility

• Equip duty rooms with furniture, computer, and /or internet access.

• Prepare a cupboard/ locker for all staff to secure all their personal belongings, gowns, and uniforms.

• Ensure 24 hrs. access to water (portable purifier)

• Avail Central coffee and tea service.

• Conduct regular duty room housekeeping service with daily cleaning and linen change service.
 Primary Hospital Level Interventions
Laboratory and Diagnostic services

• Establish an audit and monitoring system for at least ten prioritized lab test
reagents and supplies.
• Conduct weekly audit
• Establish a system of auditing justifications for major laboratory/imaging
requests.
• Conduct weekly audit
• Establish a system of auditing laboratory and imaging requests sent outside
the institution for unacceptable reasons.
• Conduct weekly audits at OPD.
 Primary Hospital Level Interventions
Pharmaceutical services
• Decide on a list of 10 prioritized drugs and Monitor using the Dashboard weekly.
• Prioritization should consider cost, risk of addiction, and drug resistance.
• Decide on a list of 5 prioritized supplies and Monitor using the Dashboard.
• Prioritization should consider cost and market availability.
• Conduct regular audits on the appropriate use of drugs and supplies for CBHI, credit, and
exempted services.
• Conduct weekly audit
• Establish a staff clinic with an assigned physician. Annex 13 Staff Clinic Protocol.
 Primary Hospital Level Interventions
Outpatient Service
• Early initiation of OPD services before government working hours.

• Implement a block appointment system for chronic OPD and ANC clinics
based on patient volume.
• At least morning and afternoon blocks

• Implement the standard protocol for proper management of chronic care

clinics.

• Implement provision of regular patient education and counseling services on

selected common illnesses.
 Primary Hospital Level Interventions
Inpatient care
• Conduct MDT rounds twice daily, led by the most senior staff in the unit.
• Night-time MDT rounds are to be done for new and critical patients.
• Night-time MDT rounds are to be done for new and critical patients.

• Conduct inpatient performance review and improvement forum weekly.

• Implement nursing handover practices during all shifts with different modalities.
• Implement nursing care process for all admitted patients.
• Nursing care process should be completed within 2 hours of inpatient
admission.
 Primary Hospital Level Interventions

Inpatient care Cont…

• Provide client education for all admitted patients.

• Conduct regular nursing clinical audits.
• At least two nurses should be assigned as permanent audit team who will be
members of the SBFR task force to conduct:
• 1. Chart audit for nursing care plan
• 2. Client interview and observation.
Primary Hospital Level Interventions

Health Center support and recognition

• Assign a team to each health center and provide mentorship and coaching monthly.
• In collaboration with WoHO, support the review meeting and PHCU performance
mentoring monthly.
• In collaboration with WoHO, select and recognize SBFR high-performing health centers
and health posts.
 WoHO level interventions

High-impact leadership and coordination.

• Establish a woreda-level SBFR PHCU task force with a TOR.

• Adopt/Adapt Woreda health office level dashboard and conduct dashboard-based weekly WoHo's SBFR performance review.
• Conduct SBFR implementation status experience learning review meetings with pilot facilities under the woreda every quarter.
• (The meeting can be conducted preferably in the compound of a better-performing health facility on a rotation basis.
• Conduct regular and sudden supervision every two weeks in randomly selected health facilities and generate reports on the findings quarterly.
• Conduct sudden supervision without notifying the facilities during nighttime, weekends, and holidays
• Report SBFR performance to zone /RHB monthly.
 WoHO level interventions

Emergency, liaison referral, and ambulance management

• Check regular ambulance functionality.

• interview at least one primary hospital, two health centers, and
two health post liaison officers weekly via telephone about the
availability of an ambulance when needed.
 WoHO level interventions

Recognition of best-performing facilities

• Recognize at the mid and final phase of the project of best-performing

health facilities
• One health center and two health pots
 Zonal Health Department-Level Interventions

High-impact leadership and coordination.

• Establish a ZHD-level SBFR PHCU task force with a TOR.

• Monitor and follow the implementation of the QI project based on the identified gaps at
primary Hospitals and general hospitals
• conducting supportive supervision monthly
• Conduct sudden visits randomly in collaboration with WoHO to primary hospitals and
general hospitals quarterly
 MoH National Quality & Innovation SBFR Steering
Committee
HSIQ LEO National PHCU SBFR Project Team

RHB RHB PHCU-SBFR project Team

INTEGRATION AND COORDINATION
ZHD PHCU-SBFR Taskforce
OF THE PROJECT IMPLEMENTATION
ZHD

WoHO Woreda Education Office

WoHO Taskforce
Hospital, Health Center
Health Facility
Taskforc

Health Post focal

HP

Community Level School Health club

Figure 1 the coordination mechanism of PHCU SBFR
 INTEGRATION AND COORDINATION OF THE PROJECT IMPLEMENTATION

MoH •Project management Project management

National Quality & Innovation SBFR Steering Committee

HSIQ-LEO

RHB

Zonal Health department

Woreda Health office

Primary Hospital

Health center

Health Post

School

Project management
PERFORMANCE and Knowledge Management
M and E framework
Indicators
Data Analysis and synthesis
Data quality
Dashboard
Performance review and learning
M and E Framework
Inputs Process Outputs Outcomes

.
Health information systems and Performance measure: dashboard Improved coordination and
Digitization clinical audit collaboration Improve Health outcomes.
Competencies and productivities of Executing Teachers Led Household Visits Improved efficiency of Service Improved patient experience of
health workers Implementing Intensive monitoring and delivery care
Stakeholder engagement and feedback Mechanism Improved Adherence of HEP Reduced health inequities.
contribution mechanisms. Household and community engagement package implementation
Protocols/Audit tools Intensive monitoring of EPHCG Improved quality of care
Technical and financial support implementation
Conducive working environment Regular SBFR taskforce meeting
Recognizing best performing units
Learning and experience sharing mechanisms

PHCU-SBFR Project Data source, Analysis and learning systems.

Community and Facility Based Assessments’, CVRS, HMIS,

Data source Admin report (web-based platforms), CHIS, HMIS, Baseline and follow Mortality surveillance and response systems (MPDSR, POMR,
up assessments, supervision reports, audit summary sheets, VA summary).

Analysis and synthesis Data quality assurance and feedback cycles, use of Dashboards, Community Scorecards, Performance against target, comparison of baseline
and follow up,
Woreda and HF based learning collaborative sessions, experience sharing visits, Performance review meetings, publish lessons and best
Learning system practices, feedback mechanism, SBFR Taskforce meetings,

Data source;
Indicators
The existing indicators from the various national routine health information systems and health facility assessments, along with
new indicators, which will be extracted from
 the project assessments,
 performance audits, and
 supportive supervision, were included.
 The baseline performance will be obtained from existing data sources for those indicators aligned with available information

systems, including
 HMIS, HCMIS, the public health surveillance, and mortality review systems, by extracting data from respective data sources and the project baseline
assessment findings.

 The indicator matrix (annex 2) outlines the list of indicators with baseline, target, data sources, frequency of data collection,

and responsible body for data collection under the expected results categories outlined in the conceptual framework.
 Data analysis
• Regular data analysis will be done by SBFR project team, in collaboration with
national, Regional, and (targeted zonal, woreda, and health post levels)
• The analysis deals for KPI
• This includes comparing
o Target against achievement/standard
o
Baseline and follow-up performance
o Trend analysis/constructing run charts and control charts.
o Data quality assurance and feedback cycles
o Use of Dashboards
o Community Scorecards
 Annexes
• Annex 1: SBFR TASKFORCE TERMS OF REFERENCE (TOR)
(SAMPLE)
• Annex 2: SBFR -PHCU Project Indicator matrix
• Annex 3: Health post-level dashboards
• Annex 4: SBFR monitoring Dashboard for Health centers.
• Annex 5: WoHO level Dashboard
 Annexes
• Annex 6: Emergency Care Chart Audit Template

• Annex 7: Client interview checklist

• Annex 8: Outpatient care Chart audit template

• Annex 9: In-patient Chart Audit Template

• Annex 10: Selected targeted woredas.

 Summary
• Positive progress on – Health center
ensuring access – Primary hospital and
– WoHO
• Gaps in quality, safety, and
equity • Integration, robust
monitoring, evaluation,
• Invest less harvest more
and learning
• Innovative interventions
– Health post and community
Thank you!