The response rate was 100% for both the KIIs and service-related data collection. IPOS implementing districts had an average of 33 technical and 20 support staff. The average number of hard-to-reach kebeles in the IPOS implementing districts were 9, and 86% of them were targeted for IPOS.
The IPOS implementing districts reported that they required the strategy due to lack of access in providing RMNCAH-N services, as there were almost no HFs nearby, and they were troubled by shortage of transport services, long distances of HFs from communities, security challenges, and pastoralist communities that move from place to place. According to their report, IPOS was conducted three times per year and integrated services were provided to improve service coverage and save lives.
The average numbers of health and administrative staff interviewed in HCs were 17 and 13, respectively. There were six hard-to-reach kebeles per HC, and 87% of them were targeted for IPOS implementation. HC staff mentioned the same reasons as district health office staff for the initiation of IPOS in their catchment areas. The implementation of IPOS in HCs also occurred about three times a year, which was the same frequency as reported by district staff.
In districts with HPs, the average number of health extension workers were found to be two. The duration of the implementation of IPOS and the potential reasons for the implementation were the same as that of the districts and HCs.
Implementation status
All the assessed districts, HCs and HPs reported that preparatory activities like training, microplanning, and community mobilization were conducted before the actual implementation of the sessions. However, training was provided only for 60% of HPs, and adequate community mobilization activities were conducted in 80% of the HPs during the last sessions.
Only 60% of the districts and 20% of HCs had adequate transport facilities to support IPOS implementation. During the IPOS sessions, integrated RMNCAH-N services including antenatal care (ANC), family planning (FP), vaccination, nutrition, and sick child and malaria treatments were provided to clients. In addition, some social and behavior change communication (SBCC) activities were also integrated to promote key health and nutrition messages.
IPOS activities were conducted regularly in 80% of districts, 60% of HCs, and 80% of HPs. The same findings were reflected by managers at different levels of the health system during KIIs. The managers of the district health offices commented,
Some kebeles in our districts were found to be hard-to-reach and had difficult terrains, making it challenging to provide services on a routine basis. Therefore, the implementation of quarterly IPOS was very important to improve service access for our communities.
Guidelines and protocols were utilized during service provision in all districts, HCs, and HPs, and the services were being properly recorded during the sessions at all levels.
Service tracking mechanisms were found to be universal at HCs, but only 40% of districts and 60% of HPs had the systems. Eighty percent of districts and HCs, and 60% of HPs experienced shortages of logistics and supplies while they were conducting the last two sessions of IPOS. The common shortage in commodities during IPOS implementation were Implanon, iron folate, Coartem, rapid diagnostic tests (RDTs) and dispersible amoxicillin (Table 3).
Table 3
Preparatory activities and implementation status of IPOS at USAID Transform: Primary Health Care intervention areas, 2017–2020.
Indicators | Districts | Health centers | Health posts |
Preparatory activities | Session 1 | Session 2 | | Session 1 | Session 2 | | Session 1 | Session 2 | |
Training/ orientation provided for staff before the sessions | 100% | 100% | | 100% | 100% | | 100% | 60% | |
Microplanning before the sessions | 100% | 100% | | 100% | 100% | | 100% | 100% | |
Adequate community mobilization before the sessions | 100% | 100% | | 100% | 100% | | 100% | 80% | |
Sessions | | | | | | | | | |
Adequate transport facility for staff and transport to IPOS sites | | | 60% | | | 20% | | | |
ANC provided during IPOS | 100% | 100% | | 80% | 80% | | 100% | 100% | |
FP services provided during IPOS | 100% | 100% | | 100% | 100% | | 100% | 100% | |
EPI services provided during IPOS | 100% | 100% | | 100% | 100% | | 100% | 100% | |
Nutrition services provided during IPOS | 100% | 100% | | 100% | 100% | | 100% | 100% | |
Sick child services provided during IPOS | 80% | 80% | | 80% | 80% | | 100% | 100% | |
Malaria services (RDT testing and treatment) provided during IPOS | 100% | 100% | | 100% | 100% | | 100% | 100% | |
SBCC activities conducted during IPOS | 80% | 80% | | 100% | 100% | | 100% | 100% | |
IPOS activities conducted regularly | | | 80% | | | 60% | | | 80% |
Guidelines and protocols utilized for services during IPOS | 100% | 100% | | 100% | 100% | | 100% | 100% | |
IPOS services properly recorded during the sessions | 100% | 100% | | 100% | 100% | | 100% | 100% | |
Presence of mechanisms to track services delivered during IPOS | | | 80% | | | 100% | | | 60% |
Shortage of logistics and supplies during the last two sessions | 80% | 80% | | 80% | 80% | | 60% | 60% | |
Progress monitoring
All IPOS implementing districts had a mechanism to supervise IPOS activities implementation. In addition, the districts had a mechanism to monitor the contribution of IPOS on the improvement of RMNCAH-N programs. Eighty percent of IPOS implementing districts conducted review meetings to review progresses and related challenges in the process of IPOS implementation.
Ownership and sustainability
Management teams were informed about the strategy and had assigned focal persons to coordinate activities in 80% of the IPOS implementing districts, and 40% of their catchment HCs. Forty percent of the districts implementing IPOS allocated budgets for the regular implementation of the strategy, and 20% of the HCs conducted IPOS using their own budgets.
According to the reflections of all HC heads, IPOS is a useful strategy to address service inequity and improve performance. All districts were willing to continue IPOS implementation at their respective districts and have plans to allocate budgets for the implementation of the strategy in the future. The participants of the KIIs also indicated that as partners’ projects have their own lifetime and will phase out, it will be the responsibility of the government to sustain the program. A participant commented,
“USAID Transform: Primary Health Care has shown us how to [conduct the initiative] and we have seen the contribution of IPOS in terms of improving access. It will therefore be the responsibility of the HC to allocate resources and continue its implementation”.
Eighty percent of district administration offices were willing to allocate budgets for IPOS implementation and 80% of district health offices had a plan to expand HFs to the remote kebeles in the future to improve service access.
Community engagement and participation
All IPOS implementing districts and HFs were engaging and involving community leaders/volunteers in the process of IPOS implementation. The community had accepted all the packages of services being provided during IPOS, and service utilization was found to be good based on the testimonies given by the EPI focal of the public sector and coverage indicators. According to the participants of the KIIs, district managers, health workers, community volunteers, and other sectors were engaged and playing key roles in the implementation of IPOS among the intervention districts.
Maternal and child health services
This study delved into the trends of key maternal and child health service progress—comparing the coverages before and after the implementation of IPOS. Below are trends in some of the key maternal and child health services before (2017) and after (2018 to 2020) the implementation of IPOS in the intervention districts.
Immunization services
There was progressive improvement in immunization coverages among IPOS implementing districts and HFs. Antigens like Penta 1, Penta 3, MCV1, and full immunization have shown significant increment among IPOS implementing districts and HFs over the years, (2017–2020). The average yearly increment for Penta 3 was 7%, 18%, and 13% in districts, HCs, and HPs, respectively (Fig. 1).
Most of the participants of the KIIs said that,
“IPOS helped to serve the hard-to-reach community, i.e., the community got better access to health services which improved health service coverage, especially in RMNCAH-N services, including EPI”.
A paired sample t-test was used to determine whether there was a statistically significant mean difference on immunization service indicators before and after the IPOS implementation. The assumption of normality was not violated, as assessed by the Shapiro–Wilk test, Penta 1 (p = .130), Penta 3 (p = .151), MCV1 (p = .166), and fully immunized (p = .238). Facilities performed better after IPOS implementation as compared to before (Table 4), with a statistically significant increase of 29.357 (95% CI, 12.561 to 46.153) for Penta 1, 29.443 (95% CI, 15.944 to 42.942) for Penta 3, 33.914 (95% CI, 20.002 to 47.827) for MCV1, and 34.136 (95% CI, 20.079 to 48.192) for full immunization (Table 4).
Table 4
Immunization performance Indicators, USAID Transform: Primary Health Care IPOS intervention areas, 2017–2020.
| Pre-intervention (N = 14) | Post-intervention (N = 14) | t | df | Sig. (2-tailed) | Mean difference | Std. error | 95% confidence interval of the difference |
Mean | SD | Mean | SD | Lower | Upper |
Penta 1 | 81.57 | 28.04 | 110.93 | 20.37 | 3.776 | 13 | .002 | 29.357 | 7.775 | 12.561 | 46.153 |
Penta 3 | 70.46 | 30.35 | 99.90 | 30.75 | 4.712 | 13 | .000 | 29.443 | 6.248 | 15.944 | 42.942 |
MCV1 | 68.82 | 21.88 | 102.74 | 20.30 | 5.266 | 13 | .000 | 33.914 | 6.440 | 20.002 | 47.827 |
Full immunization | 61.01 | 27.07 | 95.14 | 29.36 | 5.246 | 13 | .000 | 34.136 | 6.507 | 20.079 | 48.192 |
Nutrition services
The proportion of children 6–59 months old supplemented with vitamin A and deworming services increased in the years between 2017 to 2020. Prior to the intervention, the average annual increment of children 6–59 months old supplemented with vitamin A had been about 10% and 19% for deworming. Nutritional screening coverage for under-five children as well as PLW has also shown significant improvement over the years (Table 5).
Table 5
Trends in nutrition services provided at USAID Transform: Primary Health Care IPOS intervention areas, 2017–2020.
Indicators | 2017 | 2018 | 2019 | 2020 |
Vitamin A supplementation (6–59 months) | | | | |
Districts | 52.8 | 76.6 | 77.2 | 87.4 |
HCs | 67.8 | 52.8 | 54.5 | 68.4 |
HPs | 66.2 | 58.4 | 110.4 | 97.0 |
Deworming (2–5 years) | | | | |
Districts | 32.1 | 67.8 | 60.6 | 76.0 |
HCs | 3.3 | 40.8 | 28.0 | 62.4 |
HPs | 28.6 | 35.2 | 99.4 | 86.6 |
Screening (< 5 years) | | | | |
Districts | 70.4 | 71.0 | 85.2 | 81.2 |
HCs | 112.5 | 121.3 | 151.0 | 159.4 |
HPs | 98.6 | 103.8 | 178.2 | 170.4 |
Screening (PLW) | | | | |
Districts | 80.4 | 117.2 | 97.2 | 106.2 |
HCs | 32.0 | 74.0 | 94.0 | 105.4 |
HPs | 55.2 | 44.0 | 80.8 | 90.2 |
Maternal health services
ANC 1 visits have shown significant improvement over the years at all levels of the health system with an average increment of 5%, 15%, and 10% among the intervention districts, HCs, and HPs, respectively. The proportion of ANC 4 plus visits have also shown improvement over the years in all of the intervention areas with the exception of two districts. The proportion of pregnant women that received the recommended doses of iron supplements (three months and above) had improved across the years from 2017 to 2020, at all levels of the health system. The average annual increment for the structures included in this assessment was over 20%. The percentage of women that had received FP services, both short and long acting, has also shown improvement, (Table 6).
Table 6
Maternal health services provided at USAID Transform: Primary Health Care IPOS intervention areas, 2017–2020.
Indicators | 2017 | 2018 | 2019 | 2020 |
ANC 1 | | | | |
Districts | 90.8 | 104.2 | 105.6 | 105.2 |
HCs | 66.5 | 89.0 | 112.4 | 112.4 |
HPs | 33.7 | 34.8 | 73.8 | 62.8 |
ANC 4 | | | | |
Districts | 69.4 | 81.2 | 64.4 | 65.8 |
HCs | 44.2 | 59.4 | 74.8 | 73.6 |
HPs | 25.4 | 24.0 | 46.4 | 44.8 |
Fefol supplementation for pregnant women (≥ 3 months) | | | | |
Districts | 20.8 | 39.4 | 76.7 | 102.2 |
HCs | 19.8 | 47.6 | 80.7 | 87.6 |
HPs | 14.4 | 21.4 | 84.8 | 84.4 |
FP | | | | |
Districts | 39.8 | 45.2 | 52.2 | 54.4 |
HCs | 72.7 | 79.6 | 89.4 | 89.8 |
HPs | 33.7 | 36.0 | 80.4 | 79.4 |
Long-acting reversible contraceptives | | | | |
Districts | 20.4 | 27.4 | 36.6 | 38.2 |
HCs | 20.7 | 16.8 | 34.0 | 46.8 |
HPs | 20.7 | 21.8 | 35.6 | 44.6 |
Short-acting FP | | | | |
Districts | 53.2 | 49.0 | 49.0 | 50.4 |
HCs | 81.0 | 92.2 | 88.4 | 85.6 |
HPs | 40.0 | 45.0 | 86.4 | 80.6 |
Sick child treatment
The proportion of sick children seeking pneumonia treatment with antibiotics and children with diarrhea that received oral rehydration therapy (ORT) and zinc has increased across the years, from 2017 to 2020. At the HP level, the average increment was 12% and 5% for pneumonia and diarrhea, respectively (Table 7).
Table 7
Trends in treatment for sick children at USAID Transform: Primary Health Care IPOS intervention areas, 2017–2020.
Indicators | 2017 | 2018 | 2019 | 2020 |
Antibiotics given to under-five children with acute respiratory infection | | | | |
Districts | 28.3 | 15.8 | 36.3 | 49.8 |
HCs | 22.0 | 31.6 | 39.2 | 47.6 |
HPs | 14.1 | 20.2 | 36.2 | 51.2 |
ORT and zinc given to under-five children with diarrhea | | | |
Districts | 19.6 | 24.8 | 40.6 | 48.6 |
HCs | 9.5 | 34.6 | 53.0 | 86.0 |
HPs | 24.4 | 40.4 | 32.0 | 38.4 |