National Survey on Availability of Modern Contraceptives and Essential Life Saving Maternal/RH Medicines in Service Delivery Points in Ethiopia

Publication date: 2010

i | P a g e December 2010 Addis Ababa National Survey on Availability of Modern Contraceptives and Essential Life Saving Maternal/RH Medicines in Service Delivery Points in Ethiopia | P a g e ii FOREWORD The current policy environment is very supportive of RHCS. Several policies and strategies are being developed while others have already been adopted calling for support to reproductive health and family planning services and availability of contraceptives. The Health Policy and Health Sector Development Plan for instance make provisions for reproductive health, and family planning is mentioned in the basic health package. The health plan also stresses the importance of access to essential drugs and distribution of contraceptives and RH commodities at SDPs through effective and efficient logistics supply management system. The Government believes that RHCS can only become a reality when every person is able to choose, obtain, and use quality contraceptives and other reproductive health commodities whenever she or he needs them. Many factors ranging from the socio-economic context of the country, to the policy environment for RH services, the availability of funds to procure commodities, the capacity of the health system to procure, store, and distribute them effectively to people when and where they are needed, affects RHCS. People need to know about RH services and contraceptive options and to seek them, which requires information. Service providers need the skills to deliver quality services. In this regard, the vision of the Government can only become a reality if the implementation process of the RHCS/LMIS is participatory and accelerated. We trust the survey on “Availability of Modern Contraceptives and Essential Life Saving Medicines in Service Delivery Points in Ethiopia” will build on the existing endeavors of strengthening the logistics management information systems and the national RH commodities quantification and forecasting initiatives at all levels. The complementary role of partners, NGOs, and other stakeholders will be very useful not only in the participation of undertaking this survey but in carrying forward the key recommendations reflected in the survey. Since 2007 UNFPA has been supporting the strengthening and mainstreaming of RHCS into the existing health system through the GPRHCS program. The purpose is to provide special support to close gaps in reaching the targets set by the Health Sector Development Plan and the health MDGs. UNFPA provided technical and financial support to undertake this important survey and will continue its support in improving RHCS of the country. Finally, on behalf of the Federal Ministry of Health and UNFPA-Ethiopia we would like to take this opportunity to express our gratitude to all partners for their continued support in this endeavor. We | P a g e iii also appeal to all of our partners in health sector to use the findings of this survey to improve the country’s RHCS. Tedros Adhanom Ghebreyesus (PhD) Mr. Benoit Kalasa (PhD) Minster of Health UNFPA Representative | P a g e iv ACKNOWLEDGEMENTS BETA Development Consulting Firm is very pleased to express its indebtedness for securing the confidence that UNFPA - Ethiopia Country Office has bestowed upon it to undertake the National Survey on Modern Contraceptives and Essential Life Saving Maternal Medicines in Service Delivery Points in Ethiopia. At this juncture, the Firm would like to surface that the good work done remains a credit of all who were engaged in the survey: FMOH, RHBs, ZHDs, WoHO, and service providers at the respective SDPs. BETA also acknowledges the field data collectors and supervisors who discharged the assignments given to them to the required standard. BETA also wishes to express its appreciation both to Dr. Michael Tekie and Mr. Ibnou Diallo of UNFPA, who closely followed-up progress of the survey by emails and over the telephone, appearing in person at BETA’s office to oversee data quality at all stages of the survey. Without the hard work of UNFPA logistics unit, the field work would not have been completed in the time frame that both BETA and UNFPA had agreed upon. | P a g e v ACRONYMS AIDS Acquired Immune-Deficiency Syndrome AMTSL Active Management of Third Stage Labour CPR Contraceptive Prevalence Rate CSA Central Statistical Agency CSPro Census and Survey Processing EDHS Ethiopian Demographic and Health Survey EHNRI Ethiopian Health and Nutrition Research Institute EmONC Emergency Obstetrics and New-born Care FMOH Federal Ministry of Health FP Family Planning GPRHCS Global Program to Enhance Reproductive Health Commodity Security HCs Health Centres HEP Health Extension Program HEWs Health Extension Workers HIV Human Immune-deficiency Virus HPs Health Posts HSDP Health Sector Development Program ICPD International Conference on Population and Development IUCD Intra-Uterine Contraceptive Device Kms Kilometres LIAT Logistics Indicators Assessment Tool MDG Millennium Development Goal MMR Maternal Mortality Ratio MPH Masters in Public Health NGO Non Governmental Organizations PATH Program for Appropriate Technology for Health PFSA Pharmaceutical Fund and Supply Agency PPS Probability Proportionate to Size RH Reproductive Health RHB Regional Health Bureau RHCS Reproductive Health Commodity Security SDP Service Delivery Point SNNP Southern Nations, Nationalities, and Peoples SPSS Statistical Packages for Social Sciences UNFPA United Nations Population Fund USAID United States Agency for International Development WHO World Health Organization WoHO Woreda Health Office ZHD Zonal Health Department | P a g e vi TABLE OF CONTENTS FOREWORD . II ACKNOWLEDGEMENTS . IV ACRONYMS . V TABLE OF CONTENTS . VI LIST OF TABLES . VII LIST OF FIGURES . IX EXECUTIVE SUMMARY . 1 SECTION I: INTRODUCTION . 6 1.1 BACKGROUND . 6 1.2 RATIONALE AND OBJECTIVES OF THE STUDY . 7 1.3 SURVEY ORGANIZATION AND MANAGEMENT . 7 1.4 SURVEY METHODOLOGY . 7 1.4.1 Survey design and sampling of facilities . 7 1.4.2 Data collection . 9 1.4.3 Data management and analysis . 10 1.4.4 Limitation of the survey . 11 1.5 OUTLINE OF THE REPORT . 11 SECTION II : SURVEY FINDINGS . 12 2.1 GENERAL INFORMATION ABOUT THE FACILITIES . 12 2.1.1 Geographic / Regional distribution . 12 2.1.2 Management of Facilities . 14 2.1.3 Distance of SDPs from source of supplies . 15 2.2 MODERN CONTRACEPTIVES OFFERED BY FACILITIES . 17 2.3 AVAILABILITY OF MATERNAL AND REPRODUCTIVE HEALTH MEDICINES . 25 2.4 INCIDENCE OF ‘NO STOCK OUT’ OF MODERN CONTRACEPTIVES . 35 SECTION III: CONCLUSION. 44 3.1 SUMMARY OF FINDINGS . 44 3.2 RECOMMENDATIONS . 45 SECTION IV: REFERENCES . 48 SECTION V: ANNEXES . 49 | P a g e vii LIST OF TABLES Table 1: Percentage distribution of surveyed service delivery points by region and facility type, October 2010 ……………………………………………………………………………………………………………………………………13 Table 2: Percentage distribution of surveyed facilities by distance from nearest warehouse/source of supplies (in Km)), October 2010 . 15 Table 3: Percentage distribution of surveyed facilities that provide FP, delivery and HIV/AIDS services, October 2010 . 16 Table 4: Percentage distribution of service delivery points offering modern contraceptive method, October 2010 . 19 Table 5: Percentage distribution of service delivery points offering at least three modern contraceptive methods by type of facility, October 2010 . 21 Table 6: Percentage distribution of service delivery points offering at least three modern contraceptive methods by urban/rural residence, October 2010 . 22 Table 7: Percentage distribution of service delivery points offering at least three modern contraceptive methods by management of facility, October 2010 . 23 Table 8: Percentage distribution of service delivery points offering at least three modern contraceptive methods by distance from nearest warehouse/source of supplies, October 2010 . 23 Table 9: Percentage of facilities reasoned-out for not offering modern contraceptive methods, October 2010 . 24 Table 10: Percentage distribution of service delivery points with any Maternal/reproductive health medicine available by different variables, October 2010 . 28 Table 11: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by type of facility, October 2010 . 29 Table 12: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by Region, October 2010 . 30 Table 13: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by urban/rural residence, October 2010 . 30 Table 14: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by management of facility, October 2010. . 31 Table 15: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by distance from nearest warehouse/source of supplies, October 2010 . 32 Table 16: Percentage distribution of service delivery points with main reasons for not offering maternal/ reproductive health medicines, October 2010 . 33 Table 17: Percentage distribution of service delivery points reasons with maternal/ reproductive health medicines not currently available in the stock, October 2010 . 34 Table 18: Percentage distribution of service delivery points with modern contraceptive methods in stock at the time of the survey by type of facility, October 2010 . 366 | P a g e viii Table 19: Percentage distribution of service delivery points with modern contraceptive methods in stock at the time of the survey by urban/rural residence, October 2010 . 377 Table 20: Percentage distribution of service delivery points with modern contraceptive methods in stock at the time of the survey by management of facility, October 2010 . 377 Table 21: Percentage distribution of service delivery points with modern contraceptive methods in stock at the time of the survey by distance from nearest warehouse/source of supplies, October 2010 . 388 Table 22: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by type of facility, October 2010 . 399 Table 23: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by Region, October 2010 . 40 Table 24: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by urban/rural residence, October 2010 . 40 Table 25: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by management of facility, October 2010 . 41 Table 26: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by distance from nearest warehouse/source of supplies, October 2010 . 41 Table 27: Percentage of facilities reasoned-out for stock out of modern contraceptive methods, October 2010 . 43 | P a g e ix LIST OF FIGURES Figure 1: Number of surveyed service delivery points by region, October 2010 . 12 Figure 2: Percentage distribution of sampled service delivery points by location, October 2010 . 13 Figure 3: Percentage distribution of surveyed service delivery points by type, October 2010 . 15 Figure 4: Percentage of service delivery points offering contraceptive methods, October 2010 . 18 Figure 5: Percentage of service delivery points offering at least three types of modern contraceptive methods, October 2010 . 21 Figure 6: Percentage of service delivery points offering at least three modern contraceptive methods by Region, October 2010 . 22 Figure 7: Percentage distribution of service delivery points with any available maternal/ reproductive health medicines, October 2010 . 25 Figure 8: Percentage distribution of service delivery points maternal/ reproductive health medicines available in stock at the time of survey, October 2010 . 33 Figure 9: Percentage of service delivery points with modern contraceptive methods in Stock at the time of the survey, October 2010 . 35 Figure 10: Percentage of service delivery points with modern contraceptive methods in stock at the time of survey by region, October 2010 . 36 Figure 11: Percentage of service delivery points with no stock out of any modern contraceptive method in the last six months, October 2010 . 39 1 | P a g e EXECUTIVE SUMMARY Background: Ensuring the availability of modern contraceptive methods and life-saving maternal/reproductive health medicines in health service delivery points is crucial in the provision of quality primary health care. It is also one of the important tasks policy makers and program managers need to consider in the design of appropriate intervention strategies toward reducing maternal mortality and achieving MDG 5. A program should ensure adequate access to methods of choice both by type and quantity. However, in a country like Ethiopia where the unmet need is very high and source of funding for supply of contraceptives is almost totally donor dependent, ensuring availability of modern contraceptive methods and other life-saving maternal/reproductive health medicines is a major challenge. The United Nations Population Fund (UNFPA) commissioned BETA Development Consulting Firm to assess the state of availability of modern contraceptives and essential life saving maternal/RH medicines in service delivery points in Ethiopia. The survey was carried out in October 2010 in nine Regional States (Amhara, Oromia, South Nations Nationalities and Peoples (SNNP), Tigray, Somali, Harari, Gambella, Benshangul Gumuz, and Afar), and two city administrations ( Addis Ababa and Dire Dawa). The objective of the assessment was to examine the availability of modern contraceptives and essential life saving maternal / reproductive health medicines in SDPs in Ethiopia, with the principal aim of obtaining information about the: i) Number of Service Delivery Points (SDPs) offering at least three modern contraceptive methods; ii) Number of SDPs where five life-saving maternal /RH medicines from UNFPA list is available in all facilities providing delivery services; and iii) Number of SDPs with ‘no stock outs’ of contraceptives within the last six months prior to the survey. The method of data collection was a descriptive, cross-sectional design. The study subjects included a representative sample of Service Delivery Points (SDPs) that provide modern contraceptive methods and maternal/Reproductive Health (RH) services in all regions of Ethiopia. The service delivery points of the country were categorized as: Primary Level SDPs (health posts and health centres); Secondary Level SDPs (rural, zonal and regional hospitals/general hospitals); and Tertiary Level SDPs (referral/specialized hospitals). The survey applied a modified version of a standard questionnaire developed by GPRHCS. A total of 255 SDPs comprised of government, private, and NGO were randomly selected from all regions of the country. The total sample size for each category of SDPs was distributed among the regions based on probability proportionate to size (PPS) scheme, where size refers to the number of health facilities by type in each region. The sample distribution included SDPs run by government (94.1%), private firms (3.5%), and NGOs (2.4%). There were 66.3%, 24.7% and 9% primary, secondary, and tertiary level SDPs, respectively. | P a g e 2 Main Findings: It was found out that 98.8% of the surveyed SDPs had integrated family planning, 92.2% child delivery, and 87.8% services to fight against the HIV/AIDS pandemic. A great majority of the facilities offer oral pills (98.8%) and injectables (98.0%) followed by male condom (95.2%), implants (75.0%), IUDs (53.6%), female sterilization (22.6%), male sterilization (16.7%), and female condom (4.0%). Oral pills and injectables are offered in all of the tertiary level facilities; while secondary level facilities provide male and female condoms, and implants. IUDs and sterilization for both sexes are being offered by tertiary level facilities. Female condom, in general, is the least offered family planning method due to the scarcity of supply (87.2%) and low demand (8.3%) to the service. Of the total 255 facilities surveyed, three were not providing family planning services at the time of the survey. Almost all of the facilities that provide family planning services (98.0%) offer at least three modern contraceptive methods. Modern contraceptives are likely being offered by a higher tier level than lower level. All of the tertiary level facilities (100%) provide at least three modern contraceptive methods. Secondary and primary level service delivery points provide contraceptives by 1.6% and 2.4% less than tertiary levels respectively. This finding is higher as compared to the National Assessment on Emergency Obstetrics and New Born Care that was conducted in 2008, where 90% of hospitals and health centres in the country did provide at least three types of modern contraceptive methods and about 98% of the health facilities reported delivering any type of modern contraceptive methods. Out of the 52 health posts surveyed, 51 (98.1%) of them offer at least three types of modern contraceptives. With the exception of SNNP (97.9%), Addis Ababa (92.9%), Somali (80.0%), and Gambella (66.7%), all the facilities surveyed in the seven regions provide at least three modern contraceptive methods. Location of facilities has little effect in the provision of modern contraceptive methods. Almost similar percentage distribution is observed in urban - rural classification of facilities. All the surveyed Mission/NGO facilities and 99% of the Government facilities provide at least three modern contraceptive methods. On the other hand, more than three-quarters (77.8%) of private-for- profit facilities provide at least three types of modern contraceptives. Facilities that do not offer modern contraceptive methods reported that lack of supply and trained personnel are the major reasons for not providing family planning services. Life-saving maternal/reproductive health medicines were available in the majority of the service delivery points surveyed. About three-quarters of the service delivery points had antibiotics (Amoxicillin (75.7%- 193 facilities), Doxicyclin (74.5% -190 facilities), Metronidazole (74.9% -191 facilities) and Oxytocin (75.7% - 193 facilities) while about two-thirds (67.1% - 171 facilities) possessed Benzathine Penicillin, Clotrimazole, Iron/Folate and Ergometrine. However, some drugs such as Azithromycin, Cefexime and Magnesium Sulfate were available in less than 15% - in 36 facilities only of the service delivery points. The availability of these maternal/ reproductive health medicines varies by type of facilities, the region where the facilities are found, urban-rural residence, health facility ownership/management and its distance from the source of supply/warehouse. The survey showed that Oxytocin, the drug of choice for active management of the third stage of labor (AMTSL), was available in all secondary and tertiary level hospitals while only about seven in ten (70.4%) of the health posts and health centres reported of having these medicines. More health centres reported the availability of Oxytocin in the current survey than the National Baseline Assessment for Emergency Obstetric Care where only 43% of the health centres reported to have Oxytocin in stock while 31% were either out of stock at the time of the | P a g e 3 interview or had had a stock out in the last 12 months, and about a quarter of health centres reported of never having had Oxytocin in stock. It was found out that Ergometrine was available in more than 90% of the secondary and tertiary level hospitals while only less than 6 in 10 (58%) health centres and health posts reported to have the drug during the survey. There is a slight improvement in the availability of Ergometrine at service delivery points compared to the National Baseline Assessment for Emergency Obstetric Care where 70% and 50% of the hospitals and health centres, respectively, reported to have Ergometrine in the stock at the time of the survey. Anticonvulsant was available in a very few health facilities that were included in the survey. Only 3 out of 10 tertiary and 1 out of 4 secondary level hospitals reported to have had magnesium Sulfate during survey time while less than 1 in 10 (8.6%) health centres and health posts had this important life-saving drug. This finding is similar to that of the National Baseline Assessment for Emergency Obstetric Care where no or very few facilities have reported utilization of magnesium Sulfate to save the lives of mothers. Urban-rural residence was found to affect the availability of these life-saving drugs. All the three life- saving maternal/reproductive health medicines were more than two times available in urban health facilities than they are in rural health facilities. This survey indicated that while 100% of secondary and tertiary level health facilities reported to have the five (including 3 essentials) life-saving maternal/reproductive health medicines, only 64% of health centres and health posts reported to have these medicines at the time of the survey. Regional variations were observed in the availability of the five (including 3 essential) life-saving maternal/reproductive health medicines. Three–quarters of health service delivery points in all regions had all the five (including 3 essential) life-saving maternal/reproductive health medicines in the stock during the survey time. All the five (including 3 essential) life-saving maternal/reproductive health medicines were available in all health facilities in Harari while only two-thirds (67%) health service delivery points in Dire Dawa and Gambella reported to have all the five (including 3 essential) life-saving maternal/reproductive health medicines in stock. Rural-urban residence of service delivery points is one of the factors affecting the availability of maternal/reproductive health medicines. This survey showed that five (including 3 essential) life-saving medicines were about three times more available in urban service delivery points (94%) as compared to rural service delivery points (34%). The main reasons as to why service delivery points are not offering maternal/reproductive health medicines include ‘no supply’, ‘not requested’ and ‘not in the facility drug list’. The main reasons for not offering Oxytocin, for example, were cited as ‘no supply’ by 33%, and ‘not in the facility drug list’ by 62.5% of the health service delivery points. Similarly, the main reasons for not offering Ergometrine was cited as ‘no supply’, ‘not requested, and ‘not in the facility drug list’ by 38%, 7% and 32% of the service delivery points, respectively. The reasons for not offering magnesium Sulfate by service delivery points were mainly due to ‘no supply’ (48.5%) or ‘not in the facility drug list’ (44%). Only 5.4% of the service delivery points mentioned ‘not requested ‘as a reason for not offering this maternal/reproductive health medicine. At the time of the survey, physical inventory of maternal/reproductive health medicines was carried out in all health service delivery points included in the survey. In this regard Oxytocin and Ergometrine were | P a g e 4 in stock in 81% and 71% of the service delivery points, respectively, while magnesium Sulfate was in stock only in 17% and Antibiotics (Amoxicillin, Benzathin Penicillin, Doxicyclin and Metronidazole) were in stock in 70-80% of the service delivery points. The most commonly cited reasons for not having maternal/reproductive health medicines in stock were “no supply” (61.2%), “not in facility drug list” (58%), and “not requested” (26%). Almost all the surveyed facilities (98.8%) had at least one type of modern contraceptive method in stock. The mean number of modern contraceptive methods available in stock at the time of the survey was estimated at 4.5. Only 1.6% of SDPs were found fully stocked with all contraceptive methods, while nearly one third (31.8%) of SDPs had five of the most common contraceptive methods in their stock at the time of the survey. Specifically, the findings indicated that large proportion of the facilities were stocked with oral pills (97.2%) followed by injectables (96.0%), male condoms (94.1%), implants (79.5%), IUCD (55.3%), female sterilization kits (21.7%), male sterilization kits (17.4%) and female condoms (5.2%). All tertiary level SDPs, 99.4% of primary level SDPs, and 96.8% of secondary level SDPs have stocks of modern contraceptive methods. Variations in stock status of contraceptive method among urban versus rural settings were observed. Only 3.9% of the SDPs operating in rural settings of the country have reported current stock out of modern contraceptive methods in contrast to no stock out at SDPs in urban residence. Although availability of male condom, oral pills, and injectable were reported in more than 90 % of SDPs in rural localities, female condom, and male and female sterilization kits were out of stock in more than 95% of these SDPs. Great variation was observed in the duration of stock out of modern contraceptive methods that ranged from 1 to 180 days with an average of 121 days (about 4 months). Five of the eight modern contraceptive methods (female condoms, male and female sterilization kits, IUCD and implants) were reported as out of stock for about five months on average. On the other hand, male condoms, oral pills and injectable were out of stock for less than two months. In the last six months prior to the survey, stock out of modern contraceptive methods was not reported in all of the primary and tertiary level SDPs; whereas, only 3.2% of secondary level SDPs experienced stock out. Regarding urban-rural stock status, only 2.6% of rural SDPs had stock out of any one of modern contraceptive methods in the last six months prior to the survey. The most frequently cited reasons for stock out were attributed to logistics management (shortage of supply, delay in delivery, SDPs specific drug list standard, delay in order placement and lack of budget), lack of trained personnel and product expiry. In conclusion, despite the Government’s effort to reduce maternal and child mortality through scaling- up reproductive health services at the grassroots, health posts and other service delivery points are still challenged by poor supply of modern contraceptive methods. Not all of the health posts, health centres and even regional hospitals (at secondary level) offer at least three types of modern contraceptive methods. Female condoms, male and female sterilization kits and IUDs remained scarce in most service delivery points. Even tertiary level SDPs are not serving fully the community with temporary modern contraceptive methods like male condom, and long acting methods like IUDs implants, female, and male sterilization. | P a g e 5 Though maternal/reproductive health medicines were less available in most service delivery points, the situation is worse at the primary level. Compared to other maternal/reproductive health medicines, essential life-saving maternal/reproductive health medicines were less available in most service delivery points. Availability of maternal/reproductive health medicines at service delivery points is influenced by factors such as type of health facility, the region in which the service delivery is located, urban-rural residence, and facility ownership. However, distance of SDPs from the nearest warehouse/source of supplies was not found to be a major cause for the lack or availability of the medicines. Main Recommendations: In general, to improve the provision of modern contraceptives and essential life saving maternal/RH medicines in SDPs in Ethiopia, more should be done to: - Ensure that all SDPs provide at least normal child delivery service to curtail maternal mortality caused by unskilled deliveries. - Avail at least one form of family planning service at all levels. - Ensure method choice at all service delivery points. - Further expand SDPs and maintain quality of services at all levels. - Coordinate sustainable supply of modern contraceptive methods to all service delivery points. - Ensure timely forecasts and requests for modern contraceptives. - Materialize proper planning of basic and refresher training on family planning; particularly on long-acting and permanent methods as more than half of the facilities mentioned lack trained human resource to offer modern contraceptives. - Ensure the availability of maternal/reproductive health medicines in all health facilities in general and essential life-saving maternal/reproductive health medicines in particular. - Allocate budget for FP commodities and maternal health drugs and ensure that a budget line is created at all levels. - Strengthen the supply chain management systems to avail FP commodities and life saving maternal drugs to the end users at all times. - Improve functioning logistics system (avoid delay in order processing, and improve availability and supply of modern contraceptive methods at central warehouse). - Reduce average duration of stock outs for all products, minimize expiry of all products through continuous stock tracking and re-distribution mechanisms. - Ensure number of skilled human resources for the management of supplies and delivery of services. - Provide in-service training to health providers on family planning methods/products, stock and inventory management principles, customer handling and skills to practice specific methods such as IUCD insertion, implant administration, etc. - Maintain effective monitoring and evaluation for tracking the results of interventions and for deriving lessons learned to be used in guiding program implementation. | P a g e 6 SECTION I: INTRODUCTION 1.1 Background One of the Millennium Development Goals (MDGs) which most countries of the developing fourth world strive to achieve by 2015 is MDG 5 that targeted reduction of maternal mortality by three-fourth between 1990 and 2015. African countries in general and Sub-Saharan countries in particular are far behind to achieve this ambitious goal. Ethiopia is one of the Sub-Saharan African countries with highest MMR with 673 maternal deaths per 100,000 live births. [1] The maternal mortality ratio in Ethiopia has declined steadily from 1,040 per 100, 000 live births in 1990, down to 673 in 2005. [2] Even though the level of reduction in MMR seems to be significant it is still far below the annual reduction rate of 5.5% each year. More than 120 million women worldwide want to prevent pregnancy. Despite great progress in family planning service delivery over the last several decades, large proportion of women in their reproductive age and their partners are not using contraception. Among the very many reasons for unmet need, lack of services and supplies, limited choices, partner’s opposition, worries of side effects and health concerns, and lack of knowledge about contraceptive methods pose dreadful barriers. [3] By helping women avoid unwanted and poorly timed pregnancies, contraception can save the lives of millions of women and infants each year. However, most family planning programs, particularly in Africa, are bottlenecked by the ill-continued supply of contraceptives; they commonly rely on supplies from international donors for the foreseeable future. [4,5,6] Functioning of the system for obtaining adequate supply of contraceptives and other RH supplies including delivery mechanisms to SDPs remained a critical element of family planning and other RH programs. Without the commodities, services, and the logistics system, no program can meaningfully improve the reproductive health needs of the people it serves; in short ‘No product, No program’. Anecdotal evidences depict that more than 20 million women lack access to basic contraception globally. Often, these women are forced to travel long distances to access health facilities, which most of the time suffer from stock outs. [7] Stock out is a situation whereby products are temporary unavailable on the shelf or in the warehouse. Incidence of stock out occurs as a result of poor stock planning and unavailability of products. Furthermore, limited human capacity, weak transportation and poor inventory systems lead to delays in supply of delivery to SDPs. [8] Moreover, warehousing capacity could be another bottleneck for regular supply. [9] Improvement of maternal health service delivery system should be addressed by all stakeholders if the country is to meet the MDG 5. Service delivery improvement implies the construction of adequate infrastructure and improving quality of services provided in health facilities. In addition, equipping health facilities, availing trained health personnel, and adequate supply of modern contraceptives and life-saving maternal/reproductive health medicines are crucial to improve service delivery. In this regard, the government of Ethiopia has been aggressively increasing service coverage through construction of primary service delivery points and deployment of health extension workers at community level. [6] | P a g e 7 1.2 Rationale and Objectives of the Study Ensuring the availability of life-saving maternal/reproductive health medicines in health service delivery points is one of the important tasks that policy makers and program managers need to consider in the design of appropriate intervention strategies toward reducing maternal mortality and achieving MDG 5. There are little or no studies done to determine the availability of modern contraceptives and life-saving maternal/reproductive health medicines in health facilities on large scale in Ethiopia. This survey was, therefore, conducted to assess the availability of modern contraceptives and maternal/reproductive health medicines at service delivery points in Ethiopia. Specifically, the survey examined the availability of modern contraceptives and essential life saving maternal / RH medicines in 255 SDPs, with the major aim of obtaining information about the: 1. Number of Service Delivery Points (SDPs) offering at least three modern contraceptive methods; 2. Number of SDPs where five life-saving maternal /RH medicines from UNFPA list is available in all facilities providing delivery services; and 3. Number of Service Delivery Points with ‘no stock outs’ of contraceptives within last six months. 1.3 Survey Organization and Management The Federal Ministry of Health issued a letter to all the Regional Health Bureaus requesting their support in the national survey on availability of modern contraceptive methods and essential life-saving maternal/RH medicines in service delivery points in Ethiopia. The field work including determining the routes that the teams would take to visit the selected facilities, field supervision/spot check and communication with regional, zonal and woreda health offices was organized by BETA Development Consulting Firm. UNFPA facilitated all transportation and travel arrangements for the data collectors and closely followed up the day-to-day progress of the data collection activity. 1.4 Survey Methodology This national sample survey is based on interviews conducted at selected health facilities of the country in October 2010. Information was also collected through observation and physical count of commodities at stores of the selected facilities. 1.4.1 Survey design and sampling of facilities Study design: The study was conducted using a descriptive, cross-sectional design. The study areas included a representative sample of Service Delivery Points (SDPs) that provide modern methods of contraceptives and maternal/Reproductive Health (RH) medicines in all regions of Ethiopia. The service delivery points of the country were categorized as: | P a g e 8 a) Primary level care SDPs/facilities (health posts and health centres); b) Secondary level care SDPs/facilities/hospitals (rural, zonal, regional/general hospitals); and c) Tertiary level care SDPs/facilities/hospitals (referral/specialized hospitals). Sampling frame: List of all service delivery points that provide family planning and maternal health services in each of the regions of the country was obtained from the World Health Organization (WHO) Country Office. This list served as a sampling frame for the selection of sample facilities. Sample size: The total sample size was determined on the basis of minimum sample size required to allow the levels of analysis desired and national and regional representation of the health facilities offering modern contraceptive methods and life saving maternal/reproductive health medicines. The following formula was applied to determine the required sample size: 2 2 d p)p(1Z n − = Where n = minimal sample size for each domain, Z = Z score that corresponds to a confidence interval, p = the proportion of the attribute (type of SDP) expressed in decimal, and d = per cent confidence level in decimal. The formula was used to obtain the minimal sample size for the proportions of each category of SDPs (primary, secondary and tertiary) under the assumptions of normal distribution; making/rendering comparison between populations possible. The total sample size was estimated at 255 facilities including allowance to non-responses (under Z score for 95 per cent confidence interval and 5 per cent confidence limit). The total sample size for each category of SDPs was distributed among the regions according to the region’s share of a particular category of SDP. In other words, probability proportionate to size (PPS) scheme was employed, where size being the number of health facilities by type in each region. The specific service delivery points (SDPs) included in the study were chosen using systematic sampling scheme, in which an SDP had equal chance of being selected for the sample. The health facilities of each region were listed alphabetically and a sampling interval (i) was determined for each region. This was done by dividing the total number of facilities in the region by the sample size for that region: Where: i = sampling interval for the domain, N = number of SDPs in the domain, and n = sample size for that domain A starting point K was selected by randomly selecting a number between 1 and i (the sample interval). Then successive SDPs for inclusion in the sample were selected by moving at the interval K+i; K+2i; K+3i; K+4i; K+5i; etc., until the required sample size from the region was obtained. n N i = | P a g e 9 1.4.2 Data collection Recruitment of data collectors: BETA reviewed its roster of data collectors (who previously worked for the firm) and asked them for their availability for the task. In addition, some new data collectors were approached to send their curriculum vitae, interviewed and briefed on the time frame, commitment and disciplines that the task requires. As a result, 42 data collectors were identified and recruited for the training. Data collection instrument: Data were collected using structured data collection tool. The instrument was based on the generic questionnaire developed by Global Program to Enhance Reproductive Health Commodity Security (GPRHCS). The survey questionnaire included mostly close-ended questions and consisted of five sections. The questionnaire collected information on name, location and distance of SDPs to the nearest warehouse; SDP type and service provided; modern contraceptive methods provided at SDPs; availability of maternal/ RH medicines; and on stock status of modern contraceptive methods at SDPs. Training of data collectors: A training manual was developed and used in facilitating the training. The curriculum is designed in such a way that data collectors understand the concepts used in the data collection tool, purpose of the survey and how to administer the questionnaire. Brief descriptions of each RH and essential maternal health commodities have been included in the manual to make data collectors well informed about the medicines. A total of 42 data collectors, who have health related background (Nurses, Health Officers and MPH holders) showed up for a three-day training. This training was conducted between October 7 and 9, 2010. The training focused on the concept and methodology of the survey so that data collectors would be able to conduct the data collection task efficiently and effectively. The mock interview exercise particularly helped the data collectors to better understand each question included in the questionnaire and to come up with very relevant issues for clarification. Immediately after the training, the data collectors were organized into 21 teams (2 data collectors per team) and were assigned to the eleven regions throughout the country. Data collectors were supplied with the necessary data collection tools including list of selected health facilities and a copy of support letter from the Federal Ministry of Health (FMOH). Contact persons of the teams, who also served as supervisors, were given mobile cards to facilitate easy communication with BETA and UNFPA technical teams. Data quality: Data collection started on October 11, 2010 and completed on October 22, 2010. BETA technical team established close and regular contact with the supervisors to follow up their movements, problems encountered, and give them feedback on issues they raised both from administrative and technical perspectives. In addition, BETA technical team visited some areas to check data quality. Accordingly, some consistency checks were made and corrective measures were taken on the spot. A dependable supervisor among the teams who had completed the field work was contracted and assigned to follow up with the standards and clarity of the data completed and, when necessary, to visit sites (the specific health facility) to clarify some points in the questionnaire. | P a g e 10 1.4.3 Data management and analysis Review of the filled-in questionnaires: To ensure the quality of the survey data, the filled-in questionnaires retrieved from the field were reviewed and checked for consistency and completeness prior to the data entry process. During this activity some inconsistencies and incomplete responses were encountered and fixed through consulting the respective data collectors and field supervisors. Data entry application development: After checking the filled-in questionnaires manually and making them ready for data capture, the data entry application was developed using Census and Survey Processing System (CSPro) version 4.0. CSPro is a software package that has data entry, batch editing and tabulation modules including other tools that are useful in analyzing and organizing survey and census datasets. In preparing the data entry application, a data dictionary, questionnaire-oriented entry screens, and appropriate skip patterns were developed and tested using some completed questionnaires. The data entry process was also automated to minimize human errors that can be introduced in accessing application programs and data files. Orientation to the entry clerks: A brief orientation was given to the data entry clerks before carrying out the actual data entry work. This included a brief introduction to the survey questionnaire, the data entry screens and how the entry system works. Finally, before starting the actual work, the data entry clerks were given some time to enter data from some filled-in questionnaires and familiarize themselves with the data entry procedures. Data entry process: The data entry work was done on double entry basis, i.e., both entry operators did the first phase of data entry and then data entered by one operator was verified by the other, by re- entering the data. This significantly helped in improving the quality of data. The overall data entry and verification work took about ten working days. Conversion to SPSS format: Before converting the data to SPSS, basic consistency and completeness checks were done on the data in CSPro or text format using the CSPro batch editing facility. Then, variables and value set labels were reviewed and the data was converted to SPSS format. Data cleaning: The data cleaning process included checking and fixing inconsistent and incomplete responses through making necessary references to the filled-in questionnaires. Frequency distributions of all variables in the dataset and additional cross tabulations were produced to facilitate the cleaning process. Another important part of cleaning the survey data was making necessary checks to ensure the correctness of the distribution of service delivery facilities in the survey by region and type of facility. To this effect, health facilities in the dataset were checked against the filled-in questionnaires in detail and some discrepancies found between the expected and actual health posts were resolved. Data analysis: Data analysis was done using SPSS version 10. Descriptive statistics was made and results are presented in tables and graphs using summary measures such as percentages and means. In as much as possible the data is disaggregated by different variables to see the relationship between these variables. | P a g e 11 1.4.4 Limitation of the survey Readers should keep in mind the following study limitations. While collecting data at the service delivery points, we observed some limitations in the questionnaire layout. For instance, the spaces provided for the open ended responses in questions 10, 12, 12a, 14, and 17 were not sufficient to accommodate the responses. Moreover, incompleteness of records on stock and bin cards accompanied with service providers that have served for less than six months may affect the quality of data on stock out for the reference period. 1.5 Outline of the Report This report is organized in three broad sections. The first section is the introduction part which covers background information including rationale and objective of the study and survey methodology. Section two covers the findings of the survey pertaining to general information about the surveyed facilities, modern contraceptives offered by the facilities, availability of maternal and RH medicines, and availability as well as incidence of stock out of modern contraceptives. The last section concludes the report by summarizing the study findings and providing programmatic recommendations. | P a g e 12 SECTION II: SURVEY FINDINGS 2.1 General Information about the Facilities Overview: With an estimated population of about 77 million, the physician-population ratio in Ethiopia was 1:36,158, accessed through 16,898 health facilities (including 195 hospitals, 1,362 health centres, and 12,488 health posts). [10] In the survey, the health service delivery points (SDPs) have been classified as primary (health posts and health centres), secondary (rural, zonal and regional hospitals), and tertiary (referral and specialized hospitals). The first point of contact in the health care system in the rural setting, where about 82% of the total population resides, [1] is the health post, which provides preventive health care comprising 16 packages (the major areas being family health, disease prevention and control, hygiene and environmental health, and health education). The catchment population size that one health post addresses is about 5,000 [10] and staffed by two female Health Extension Workers (HEW), who have completed 10 th grade schooling and one year training in the promotion of preventive health care at the grassroots level. The health centres mainly provide basic curative care services and act as referral and technical assistance centres for five HP. [11] Hospitals at secondary levels are the backstops for the health centres as the tertiary levels are for the former. 2.1.1 Geographic / Regional distribution The survey was conducted in nine regional states (Amhara, Oromia, South Nations Nationalities and Peoples (SNNP), Tigray, Harari, Gambella, Benshangul Gumuz, Somali and Afar), and two city administrations (Addis Ababa and Dire Dawa). Figure 1: Number of surveyed service delivery points by region, October 2010 | P a g e 13 Of the total number of surveyed health facilities, the majority were from Oromia Region (80 facilities) followed by Amhara (51 facilities) and SNNP (48 facilities). The least number of facilities were drawn from Dire Dawa and Gambella (three facilities each). On the other hand, 70.2% (179/255) of the surveyed health facilities were located in urban settings as opposed to 29.8% in the rural (see graph bellow). Figure 2: Percentage distribution of sampled service delivery points by location, October 2010 The findings also show that no HPs were surveyed in Harari and Addis Ababa. By the same token, regional hospitals in Amhara and Dire Dawa, referral hospitals in Afar, Benshangul Gumuz, Gambella , and Tigray had slipped of the random selection, as was the case with the rural and zonal hospitals in about six of the regions. Table 1: Percentage distribution of surveyed service delivery points by region and facility type, October 2010 Region Percentage/ type of health facility Total Health post Health centre Rural hospital Zonal hospital Regional hospital Referral (specialized) hospital Tigray 23.8 38.1 19.0 14.3 4.8 0.0 21 Afar 20.0 40.0 20.0 0.0 20.0 0.0 5 Amhara 23.5 49.0 13.7 3.9 0.0 9.8 51 Oromia 25.0 41.3 8.8 16.3 2.5 6.3 80 Somali 20.0 40.0 0.0 0.0 20.0 20.0 5 Benshangul Gumuz 16.7 50.0 0.0 16.7 16.7 0.0 6 SNNP 20.8 47.9 14.6 10.4 2.1 4.2 48 Gambella 33.3 33.1 0.0 0.0 33.3 0.0 3 Harari 0.0 20.0 0.0 0.0 20.0 60.0 5 Addis Ababa 0.0 64.3 0.0 0.0 14.3 21.4 28 Dire Dawa 33.3 33.3 0.0 0.0 0.0 33.3 3 Total 20.4 45.9 10.2 9.4 5.1 9.0 255 | P a g e 14 The HPs that had formed 20.4% of all surveyed SDPs were all government owned structures. Among the SDPs surveyed and segregated by level, the HCs formed the highest proportion (45.9%) followed by the HPs. The zonal regional, and referral / specialized hospitals formed 10.2%, 9.4%, 5.1%, and 9.0% of all surveyed facilities, respectively (see Table 1). 2.1.2 Management of Facilities The survey has addressed government, NGO and private health facilities understanding that the latter two complement efforts of the FMOH to address the health needs of the people. “ The major foci of the health policy are democratization and decentralization of the health care system, development of the preventive, promotional and curative components of health care, assurance of accessibility of health care for all segments of the population and the promotion of private sector and NGOs participation in the health sector. The national health policy focuses on a comprehensive health service delivery system to address mainly: • Communicable diseases, • Malnutrition, and • Improving maternal and child health. The health service delivery system is decentralized with responsibility for implementation being largely devolved to the districts which plan on the basis of block funding for the sector. The Policy emphasizes inter-sectoral collaboration, particularly in ensuring family planning for optimal family health and population planning, in formulating and implementing an appropriate food and nutritional policy and in accelerating the provision of safe and adequate water for urban and rural populations.…” [12] Therefore, among the SDPs that were surveyed, 94.1% of them represented government as opposed to 3.5% privates and 2.4% NGOs. In a nut shell, the primary SDPs were represented in the survey by 66.3%, the secondary by 24.7%, and the tertiary by 9% (see Figure 3 below). | P a g e 15 Figure 3: Percentage distribution of surveyed service delivery points by type, October 2010 2.1.3 Distance of SDPs from source of supplies The SDPs run their programs through budgeted and non - budget supplies. Among the non-budgeted supplies, one is the modern contraceptive commodity. The facilities collect their unbudgeted supplies either from woredas, zonal, or regional stocks of the FMOH. Therefore, facilities answerable to the Woreda Health Office (WoHO) collect their commodities from the Woreda Health Offices. Those answerable to the zone collect from Zonal Health Departments (ZHD), and the regional ones from the Regional Health Bureau (RHB). Therefore, distance of the SDPs from their source of supplies was found to be varying from less than one kilometre to 50 and more kilometres. In this regard, 44.3% of them, that form the highest proportion, were situated about 50 and more kilometres from the source; followed by 16.1% that were situated at 00 to 4 kilometres, and 11% between 5 and 9 kilometres from the source; and the rest, ranging from 0.4 % to 8.6% were situated within the reach of 1 to 22 kilometres (see Table 2). Table 2: Percentage distribution of surveyed facilities by distance from nearest warehouse/source of supplies (in Km), October 2010 Distance from nearest warehouse/source of supplies (in Km) Percentage n 0-4 16.1 41 5-9 11.0 28 10-14 8.6 22 15-19 5.9 15 20-24 4.3 11 25-29 1.2 3 30-35 3.9 10 35-39 2.4 6 40-45 0.4 1 45-49 2.0 5 50 and over 44.3 113 | P a g e 16 2.1.4 Services related to family planning, child delivery and HIV/AIDS prevention and control Given the focus area of the survey (availability of contraceptive commodities and maternal life saving essential drugs), the survey finding reflected that 98.8% of the surveyed SDPs had integrated family planning, 92.2% child delivery, and 87.8% of them one or more types of services to fight against HIV/AIDS pandemic (see Table 3). Table 3: Percentage distribution of surveyed facilities that provide FP, delivery and HIV/AIDS services, October 2010 Disaggregation Percentage n Provide family planning services Yes 98.8 240 No 1.2 15 Provides delivery services Yes 92.2 235 No 7.8 20 Provides any HIV/AIDS prevention services Yes 87.8 224 No 12.2 31 Total 100.0 255 | P a g e 17 2.2 Modern Contraceptives Offered by Facilities Overview: Anecdotal evidences show that there has been an overall increase in the use of modern contraceptive methods in the past 30 years. The contraceptive prevalence rate (CPR) has increased for a significant number of countries, including Ethiopia, Lao People’s Democratic Republic (Lao PDR), Madagascar, Mongolia and Niger. In Ethiopia, the contraceptive prevalence rate rose from 6 per cent in 2003 to 14 per cent in 2005 to 30 per cent in 2009. [5,6] In the other countries the CPR increased by 10 percentage points in Lao PDR; 11.2 points in Madagascar; 12.8 points in Mongolia and 4.8 points in Niger.[6] Though contraceptive prevalence rate has been increasing in the last three decades, Ethiopia has still one of the highest maternal mortality ratios in Africa. In addition, the country has still high unmet need for family planning. The reasons include desire to have more children, lack of knowledge about contraceptive use and where to find contraceptives, health concerns, religious prohibition, husband opposition and low involvement of men.[13] Many potential clients in Ethiopia lack information or have misconceptions about long-acting methods and permanent methods, though most people know about family planning. Myths and misconceptions about these methods are also widespread. [5] The Government of Ethiopia has been exerting tremendous effort to reduce maternal and child mortality through integrated reproductive health and family planning services. The Health Extension Program (HEP) has been given high emphasis in the Health Sector Development Program (HSDP) IV of the country. [14] In 2009, the FMOH and partners including UNFPA embarked on this program that is expected to reach all woredas (districts). This program aims to tackle the high unmet need for family planning. An estimated 34 per cent of sexually active women in Ethiopia want to stop childbearing or delay their next birth by at least two years. In the same year, UNFPA’s “Global Program to Enhance Reproductive Health Commodity Security” funded Ethiopia 520,000 sets of Implanon, and more than 600 Health Extension Workers (HEWs) received training to provide family planning services. The Global Program has been supporting the Government to ensure that facilities are adequately stocked with contraceptives and essential reproductive health medicines. [5, 6] 2.2.1 Contraceptives offered by types of facilities Table 4 describes the types of modern contraceptives offered by facility types, region, residence, management and distance from the nearest warehouse. According to the findings, great majority of the facilities offer oral pills (98.8%) and injectables (98.0%) followed by male condom (95.2%), implants (75.0%), IUDs (53.6%), female sterilization (22.6%), male sterilization (16.7%), and female condom (4.0%). Oral pills and injectables are offered in all of the tertiary level facilities that include referral and specialized hospitals; while secondary level facilities (rural, zonal and regional hospitals) are likely to provide male and female condoms, and implants. IUDs and sterilization for both sexes are likely to be offered by tertiary level facilities (Figure 4). Female condom, in general, is the least offered family planning service due to scarcity of supply (87.2%) and low demand (8.3%). The low proportion of sterilization, IUDs and implants in the primary level of care could be attributed to the fact that health posts are not expected to provide these services. Facility set-up, equipment and trained human resource for these services are missing at health post level. In the Ethiopian situation, | P a g e 18 these services are commonly offered either through referral to secondary and tertiary level care centres or through community outreach sites at regular times- with mobile equipment and trained personnel. Figure 4: Percentage of service delivery points offering contraceptive methods, October 2010 Regional disparity is high in terms of contraceptive service provision. Considering all types of facilities in a region, all of the facilities surveyed in Tigray, Afar, Amhara, Benshangul Gumuz, Gambella, and Harar offer male condoms. Female condom is not available at all in Tigray, Afar, Benshangul Gumuz, Gambella, Harar, and Dire Dawa. Oral pills are accessible in all surveyed facilities of all regions except SNNP (97.9%) and Addis Ababa (92.9%). Similarly, injectables are provided in all surveyed facilities of all regions except SNNP (97.9%), Addis Ababa (89.3%), and Gambella (66.7%). IUDs are found to be scarce in all regions except Harar (100%) and Addis Ababa (92.9%). All of the surveyed facilities in Tigray do provide implants while the least offering region is Gambella (33.3%) followed by Afar (40.0%). Sterilization is not performed in Somali region and Dire Dawa city administration. It is also the least utilized service next to female condom in all the regions. | P a g e 19 Table 4: Percentage distribution of service delivery points offering modern contraceptive methods, October 2010 Disaggregation Modern contraceptive methods M a le C o n d o m s F e m a le C o n d o m s O ra l P il ls In je ct a b le s IU D s Im p la n ts S te ri li za ti o n fo r F e m a le s S te ri li za ti o n fo r M a le s Type of Facility Primary level care SDPs (n=168) 94.6 3.6 98.8 97.6 42.3 70.8 3.6 3.0 Secondary level care SDPs (n=61) 98.4 4.9 98.4 98.4 68.9 83.6 54.1 39.3 Tertiary level care SDPs (n=23) 91.3 4.3 100.0 100.0 95.7 82.6 78.3 56.5 Administrative Unit (Region) Tigray (n=21) 100.0 0.0 100.0 100.0 42.9 100.0 19.0 9.5 Afar (n=5) 100.0 0.0 100.0 100.0 0.0 40.0 20.0 20.0 Amhara (n=51) 100.0 7.8 100.0 100.0 49.0 74.5 15.7 13.7 Oromia (n=78) 96.2 3.8 100.0 100.0 55.1 71.8 21.8 15.4 Somali (n=5) 80.0 20.0 100.0 100.0 40.0 60.0 0.0 0.0 Benshangul Gumuz (n=6) 100.0 0.0 100.0 100.0 50.0 66.7 50.0 33.3 SNNP (n=47) 97.9 2.1 97.9 97.9 38.3 72.3 21.3 17.0 Gambella (n=3) 100.0 0.0 100.0 66.7 33.3 33.3 33.3 33.3 Harari (n=5) 100.0 0.0 100.0 100.0 100.0 80.0 40.0 40.0 Addis Ababa (n=28) 78.6 3.6 92.9 89.3 92.9 82.1 39.3 25.0 Dire Dawa (n=3) 66.7 0.0 100.0 100.0 66.7 100.0 0.0 0.0 Residence Urban (n=179) 96.1 5.0 98.3 97.2 68.7 86.0 30.7 22.3 Rural (n=73) 93.2 1.4 100.0 100.0 16.4 47.9 2.7 2.7 Management Government (n=240) 96.2 4.2 99.6 98.8 52.9 76.2 20.8 15.8 Private for profit (n=9) 100.0 0.0 77.8 77.8 66.7 44.4 44.4 22.2 NGO/Mission (n=3) 66.7 0.0 100.0 100.0 66.7 66.7 100.0 66.7 Distance from nearest warehouse/source of supplies (in Km) 0-4 (n=41) 97.6 2.4 100.0 97.6 61.0 85.4 19.5 12.2 5-9 (n=28) 85.7 0.0 100.0 100.0 35.7 57.1 21.4 10.7 10-14 (n=22) 77.3 4.5 100.0 100.0 50.0 68.2 27.3 22.7 15-19 (n=15) 93.3 0.0 93.3 86.7 26.7 53.3 6.7 6.7 20-24 (n=11) 100.0 0.0 100.0 100.0 54.5 54.5 9.1 0.0 25-29 (n=3) 66.7 0.0 66.7 66.7 33.3 33.3 0.0 0.0 30-35 (n=10) 100.0 10.0 100.0 100.0 50.0 90.0 20.0 0.0 35-39 (n=5) 100.0 0.0 100.0 100.0 60.0 60.0 20.0 20.0 40-45 (n=1) 100.0 0.0 100.0 100.0 0.0 0.0 0.0 0.0 45-49 (n=5) 100.0 0.0 100.0 80.0 40.0 80.0 20.0 20.0 50 and over (n=111) 100.0 6.3 99.1 100.0 61.3 82.9 27.9 23.4 Total (n=252) 95.2 4.0 98.8 98.0 53.6 75.0 22.6 16.7 Analysis was made to see whether residence, ownership or management of facilities, and distance from the nearest warehouse of supplies of contraceptives influence provision of each contraceptive method (Table 4). There is no significant difference in urban and rural disaggregation for contraceptive delivery except for implants and sterilization, which are more likely to be offered in urban areas than rural. | P a g e 20 A great majority of government facilities (96.2%), all surveyed private-for-profit, and two of the three surveyed mission/NGO facilities do provide male condoms to clients. Female condom is available only in 4.2% of Government facilities and not at all available in private-for-profit and mission/NGO facilities. Quite a large proportion of Government facilities provide pills (99.6%) and injectables (98.8%). The same is true for private-for-profit facilities. All of the three surveyed mission/NGO facilities (a health centre and two hospitals) provide pills, injectables and female sterilization; while two of the three facilities do provide male sterilization, IUDs, and implants. Distance of the surveyed health facilities from the warehouse of supplies is not a significant factor for contraceptive service delivery. A fairly large number of facilities (111) are far from their supply warehouses with 50 and more kilometres. All of the 111 facilities offer male condoms and injectables. In addition, large proportion of these facilities offer pills (99.1%) followed by implants (82.9%), and IUDs (61.3%). The highest proportions of facilities providing both female and male sterilizations fall in this distance category. 2.2.2 Facilities offering at least three types of contraceptives Tables 5 to 10 describe facilities offering at least three modern contraceptive methods by facility tier level, region, residence, ownership of facilities and distance from supplies warehouses. Of the total 255 facilities surveyed, three did not provide family planning services at the time of the survey. These facilities are all mission/NGO owned. Almost all of the facilities that provide family planning services (98.0%) offer at least three modern contraceptive methods. Modern contraceptives are likely to be offered by a higher tier level than lower level. All of the tertiary level facilities (100%) provide at least three modern contraceptive methods. Secondary and primary level service delivery points provide contraceptives in a 1.6% and 2.4% less proportion points, respectively, than tertiary levels (Table 5). According to a national assessment on Emergency Obstetrics and Neworn Care, conducted in 2008, about 90% of hospitals and health centres in the country did provide at least three types of modern contraceptive methods and about 98% of health facilities reported delivering any type of modern contraceptive methods. [2] Similarly, a UNFPA document reported that the proportion of facilities offering at least three methods of contraceptives in Ethiopia increased from 60% in 2006 to 90% in 2009. [5] The main attribution for the increase is the rapid increase of Health Extension Workers (HEWs) in the country. Since HEWs are working at the kebele (lowest administrative unit in Ethiopia) level (two HEWs per kebele), their main supply of contraceptives are the primary health care level; health posts in particular. In this survey, the proportion of primary level facilities providing at least three types of modern contraceptives increased by 8% in just a year. More specifically, out of the 52 health posts surveyed, 51 (98.1%) of them offer at least three types of modern contraceptives (Figure 5). | P a g e 21 Figure 5: Percentage of service delivery points offering at least three types of modern contraceptive methods, October 2010 Table 5: Percentage distribution of service delivery points offering at least three modern contraceptive methods by type of facility, October 2010 Type of Facility Percentage Total (n) Offering at least three modern contraceptive methods Not offering at least three modern contraceptive methods Primary level care SDPs 97.6 2.4 168 Secondary level care SDPs 98.4 1.6 61 Tertiary level care SDPs 100.0 0.0 23 Total 98.0 2.0 252 According to Figure 6, all facilities surveyed in seven regions provide at least three modern contraceptive methods except SNNP (97.9%), Addis Ababa (92.9%), Somali (80.0%), and Gambella (66.7%). One out of three facilities in Gambella does not provide at least three modern contraceptive methods. | P a g e 22 Figure 6: Percentage of service delivery points offering at least three modern contraceptive methods by region, October 2010 Location of facilities has little impact in the provision of modern contraceptive methods. Of the total facilities that do provide family planning services, about 98% offer at least three modern contraceptive methods (Table 6). Similar percentage distribution is observed in urban and rural facilities. Table 6: Percentage distribution of service delivery points offering at least three modern contraceptive methods by urban/rural residence, October 2010 Residence Percentage Total (n) Offering at least three modern contraceptive methods Not offering at least three modern contraceptive methods Urban 97.8 2.2 179 Rural 98.6 1.4 73 Total 98.0 2.0 252 Although sample of facilities from NGO/mission and private-for-profit is very small, findings of the survey show that all of mission/NGO facilities (n=3) and 99% of Government facilities do provide at least three modern contraceptive methods. On the other hand, more than three-quarters (77.8%) of private- for-profit facilities do provide at least three types of modern contraceptives, which is lower than that of government and mission/NGO facilities. | P a g e 23 Table 7: Percentage distribution of service delivery points offering at least three modern contraceptive methods by management of facility, October 2010 Management of facility Percentage Total (n) Offering at least three modern contraceptive methods Not offering at least three modern contraceptive methods Government 98.8 1.2 240 NGO/Mission 100.0 0.0 3 Private- for- profit 77.8 22.2 9 Total 98.0 2.0 252 According to Table 8, distance from the nearest warehouse of supplies is another variable to measure availability of modern contraceptive methods. Like residence of facilities, distance has also little or no impact in the provision of modern contraceptives. The proportion of facilities that offer at least three types of modern contraceptives is sporadic with the least in the distance range of 25-29 kilometres (66.7%, n=3) and the highest (100%) in ranges of 0-4, 10-14, 20-24, 30-35, 35-39, 40-45, and more than 50 kilometres. Hence, distance is not a barrier to provide services of modern contraceptives in all types of facilities in the country. Table 8: Percentage distribution of service delivery points offering at least three modern contraceptive methods by distance from nearest warehouse/source of supplies, October 2010 Distance from nearest warehouse/source of supplies (in Km) Percentage Total (n) Offering at least three modern contraceptive methods Not offering at least three modern contraceptive methods 0-4 100.0 0.0 41 5-9 96.4 3.6 28 10-14 100.0 0.0 22 15-19 86.7 13.3 15 20-24 100.0 0.0 11 25-29 66.7 33.3 3 30-35 100.0 0.0 10 35-39 100.0 0.0 5 40-45 100.0 0.0 1 45-49 80.0 20.0 5 50 and over 100.0 0.0 111 Total 98.0 2.0 252 2.2.3 Reasons for not offering certain contraceptives The survey revealed that there are facilities that do not offer modern contraceptive methods. Table 9 analyzed the main reasons for not offering contraceptives to clients. Lack of supply and lack of trained personnel are the most commonly cited bottlenecks for temporary (male and female condoms, oral pills | P a g e 24 and injectables) and long-acting and permanent (IUDs, implants and sterilizations) contraceptive methods, respectively. As anecdotal evidences show, the main supply of modern contraceptives is international donors including UNFPA. In most cases, facilities run-out of contraceptive methods due to erratic supplies. [3- 5,15] So, the “no-supply” (even if requested and put orders before depletion of contraceptives) happens most of the time irrespective of distance and residence of facilities. “Never been requested” and “no demand for the contraceptive” are the less frequent responses provided by facilities for not providing family planning services. Unavailability of equipment is one reason why the facilities are not providing male and female sterilization and implants. Table 9: Reasons for not offering modern contraceptive methods, October 2010 Contraceptive Method No supply No trained personnel Not requested No demand Service not provided Equipment not available n Male Condoms 41.7 - 33.3 16.7 8.3 - 12 Female Condoms 87.2 1.7 2.5 8.3 0.4 - 242 Oral Pills 66.7 - - - 33.3 - 3 Injectables 20.0 20.0 - 20.0 40.0 - 5 IUDs 8.5 71.8 14.5 4.3 0.9 - 117 Implants 9.5 69.9 1.6 6.3 6.3 6.3 63 Sterilization for Females - 57.2 - 2.1 29.9 10.8 194 Sterilization for Males - 53.6 - 6.2 29.7 10.5 209 | P a g e 25 2.3 Availability of Maternal and Reproductive Health Medicines As a pre requisite for decreasing maternal mortality, all health facilities need to be equipped with life- saving maternal/reproductive health medicines with adequate quantities all the time. The findings of this survey indicated that life-saving maternal/reproductive health medicines were available in the majority of the service delivery points that are assessed by the survey. About three-quarters of the health delivery points were equipped with antibiotics (Amoxicillin (75.7%), Doxicyclin (74.5%), Metronidazole (74.9%) and Oxytocin (75.7%) while about two-thirds (67.1%)) were equipped with Benzathine Penicillin, Clotrimazole, Iron/Folate and Ergometrine. However, some drugs such as Azithromycin, Cefexime and Magnesium Sulfate were available in less than 15% of the service delivery points. Figure 7 shows the percentage distribution of service delivery points with any available maternal/ reproductive health medicines. Figure 7: Percentage distribution of service delivery points with any available maternal/ reproductive health medicines, October 2010 2.3.1 Availability of maternal and reproductive health medicines vis-a-vis types of facilities The three most important life-saving drugs known to affect maternal mortality include Oxytocin, Ergometrine and Magnesium Sulfate. The availability of these life-saving maternal/reproductive health medicines/drugs varies depending on various factors. In this survey the availability of these maternal/ reproductive health medicines varies by type of facilities, the region where the facilities are found, urban-rural residence, health facility ownership/management and its distance from the source of supply/warehouse. The survey showed that Oxytocin, the drug of choice for active management of the third stage of labour (AMTSL), was available in all secondary and tertiary level hospitals while only about seven in ten (70.4%) of the health posts and health centres reported of having these medicines. More health centres reported the availability of Oxytocin in the current survey than the National Baseline Assessment for Emergency Obstetric Care where only 43% of the health centres reported to have | P a g e 26 Oxytocin in stock while 31% were either out of stock at the time of the interview or had had a stock out in the last 12 months, and about a quarter of health centres reported of never having had Oxytocin in stock. The second most important drug used for the management of the third stage of labour is Ergometrine, a critical drug for emergency situation which should be available in all service delivery points. This survey indicated that Ergometrine was available in more than 90% of the secondary and tertiary level hospitals while only less than 6 in 10 (58%) health centres and health posts reported to have the drug during the survey. There is a slight improvement in the availability of Ergometrine at service delivery points compared to the National Baseline Assessment for Emergency Obstetric Care where 70% and 50% of the hospitals and health centres, respectively, reported to have Ergometrine in the stock at the time of the survey. Magnesium Sulphate (MgSO4) is the drug of choice for the management of pre-eclampsia/eclampsia – a leading cause of maternal mortality in facilities in Ethiopia. The survey showed that this important life- saving maternal/reproductive health medicine (anticonvulsant) was available in a very few health facilities that were included in the survey. Only 3 out of 10 tertiary and 1 out of 4 secondary level hospitals reported to have had Magnesium Sulfate during survey time while less than 1 in 10 (8.6%) health centres and health posts had this important life-saving drug. This finding is similar to the finding of the National Baseline Assessment for Emergency Obstetric Care where no or very few facilities have reported utilization of Magnesium Sulfate to save the lives of mothers. The availability of these life-saving maternal/reproductive health medicines also varies by region. The proportion of facilities that reported the availability of Oxytocin varies from 67% in Gambella to 100% in Afar, Somali, Harari and Dire Dawa. Ergometrine was the second most available life-saving medicine the availability of which varies regionally. Its availability was highest in Addis Ababa where most health facilities (84.6%) reported of having the drug at the time of the survey. On the other hand, only 50% of health facilities in Dire Dawa had Ergometrine available in stock at the time of the survey. The least available life-saving drug at the service delivery points was Magnesium Sulfate with significant regional variation. The proportion of health facilities which reported the availability of Magnesium Sulfate varies from 0% in Tigray, Afar, Benshangul Gumuz and Gambella to 80% in Addis Ababa. Urban-rural residence was found to affect the availability of these life-saving drugs. All the three life- saving maternal/reproductive health medicines were more than two times available in urban health facilities than they are in rural health facilities. Facility ownership and management was also found to affect the availability of maternal/reproductive health medicines at the service delivery points. The survey showed that these life-saving maternal/reproductive health medicines were available most at NGO and privately owned/managed service delivery points compared to the government owned health service delivery points. Ergometrine was available in all health facilities owned by NGO and private sectors while only 69% of health facilities owned/managed by Government reported of having the drug at the time of the survey. Similarly, Oxytocin was available in all health facilities owned/managed by NGOs and private sectors while the drug was available in only 80% of government owned/managed health facilities. Magnesium Sulphate was the least available drug with most NGO owned/managed health facilities (60%) reporting the availability of the drug at the time of the survey and with 11% of privately owned/managed service delivery points reporting the availability of the drug. | P a g e 27 The availability of these life-saving maternal/reproductive health medicines can also be affected by the distance of service delivery points from the source of supply/warehouse. It is reasonable to mention that facilities that are too far from the source of supply/the warehouse are less likely to have all the life- saving maternal/reproductive health medicines like facilities that are very close to the warehouse. In this survey, however, distance didn’t seem to affect the availability of maternal/reproductive health medicines at the service delivery points. Table 10 shows the percentage distribution of service delivery points with any maternal/reproductive health medicines available by various variables. | P a g e 28 Table 10: Percentage distribution of service delivery points with any maternal/reproductive health medicine available by different variables, October 2010 Disaggregating Maternal/reproductive health medicines A m o x i c i l l i n A z i t h r o m y c i n e B e n z a t h i n e P e n i c i l l i n C e f e x i m e C l o t r i m a z o l e E r g o m e t r i n e I r o n / F o l a t e M a g n e s i u m S u l f a t e M e t r o n i d a z o l e O x y t o c i n e D o x y c y c l i n e Type of Facility Primary (Health post & health centre) (n=169) 70.4 5.3 63.8 2.6 58.6 57.9 65.1 8.6 69.1 70.4 70.4 Secondary (Rural, zonal & regional hospitals) (n=63) 100 14.3 88.9 22.2 95.2 92.1 85.7 25.4 100 100 95.2 Tertiary (Referral/ specialized hospitals) (n=23) 100 4.3 78.3 39.1 95.7 95.7 78.3 30.4 100 100 100 Region Tigray (n=21) 76.2 0.0 71.4 4.8 76.2 66.7 90.5 0.0 76.2 81.0 76.2 Afar (n=5) 100 25. 100 0.0 75.0 75.0 50.0 0.0 100 100 100 Amhara (n=51) 77.6 2.0 65.3 4.1 69.4 69.4 63.3 8.2 77.6 77.6 79.6 Oromia (n=80) 77.0 5.4 71.6 12.2 71.6 67.6 75.7 23.0 77.0 79.7 75.7 Somali (n=5) 100 75 100 75 100 75.0 100 75.0 100 100 100 Benshangul Gumuz (n=6) 100 0.0 66.7 0.0 66.7 66.7 83.3 0.0 100 83.3 83.3 South Nations, Nationalities and People (SNNP) (n=48) 81.8 11.4 65.9 11.4 61.4 70.5 63.6 11.4 79.5 72.7 77.3 Gambella (n=3) 33.3 33.3 100 0.0 66.7 66.7 33.3 0.0 100 66.7 33.3 Harari (n=5) 100 40.0 100 60.0 80.0 80.0 100 80.0 100 100 100 Addis Ababa (n=28) 92.3 3.8 76.9 7.7 84.6 84.6 73.1 7.7 84.6 96.2 92.3 Dire Dawa (n=3) 100 0.0 100 100 100 50.0 50.0 50.0 50.0 100 100 Residence Urban (n=179) 94.3 9.2 83.9 14.4 86.8 82.2 77.0 17.8 93.7 96.0 93.1 Rural (n=76) 45.3 3.1 39.1 3.1 31.3 39.1 57.8 7.8 43.8 40.6 43.8 Management Government (n=240) 80.4 7.6 72.3 10.7 70.5 68.8 70.5 14.3 79.5 79.9 79.5 NGO (n=6) 100 0.0 80.0 20.0 100 100 100 60.0 100 100 80.0 Private (n=9) 88.9 11.1 55.6 22.2 88.9 100 88.9 11.1 88.9 100 88.9 Distance from nearest warehouse/source of supplies (in Km) 0-4 (n=41) 89.2 2.7 75.7 10.8 75.7 75.7 73.0 8.1 86.5 86.5 86.5 5-9 (n=28) 50.0 0.0 40.9 18.2 40.9 31.8 63.6 9.1 45.5 45.5 40.9 10-14 (n=22) 52.4 0.0 52.4 0.0 47.6 42.9 57.1 9.5 52.4 52.4 52.4 15-19 (n=15) 64.3 7.1 42.9 14.3 50.0 50.0 64.3 14.3 64.3 57.1 64.3 20-24 (n=11) 66.7 11.1 55.6 0.0 66.7 66.7 66.7 11.1 66.7 66.7 66.7 25-29 (n=3) 100 0.0 100 0.0 100 100 100 50.0 100 100 100 30-35 (n=10) 66.7 0.0 55.6 0.0 66.7 66.7 55.6 11.1 77.8 66.7 77.8 35-39 (n=6) 83.3 0.0 66.7 16.7 66.7 83.3 66.7 33.3 83.3 83.3 83.3 40-44 (n=1) 0.0 0.0 0.0 0.0 0.0 0.0 100 0.0 0.0 0.0 0.0 45-49 (n=5) 80.0 20.0 80.0 0.0 80.0 100 80.0 20.0 100 100 80.0 50 and over (n=113) 94.6 12.5 86.6 14.3 84.8 83.0 77.7 18.8 92.9 96.4 93.8 Total (n=225) 75.7 7.1 67.1 10.6 67.1 65.9 67.1 14.1 74.9 75.7 74.5 | P a g e 29 2.3.2 Availability of five essential life-saving maternal and reproductive health medicines The availability of life-saving maternal/reproductive health medicines in health facilities can be affected by various factors. The type of facilities, the region in which the facilities are located, urban-rural residence, ownership/management and the distance the facility had from the source of supply/warehouse could affect the availability of those essential life-saving maternal/reproductive health medicines in the facilities. This survey indicated that while 100% of secondary and tertiary level health facilities reported to have the five (including 3 essentials) life-saving maternal/reproductive health medicines, only 64% of health centres and health posts reported to have these medicines at the time of the survey. Table 11: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by type of facility, October 2010 Type of Facility Percentage Five (including 3 essential) life- saving maternal/reproductive health medicines available Five (including 3 essential) life- saving maternal/reproductive health medicines not available Total Primary (health post & health centre) 63.9 36.1 169 Secondary (rural, zonal & regional hospitals) 100 0.0 63 Tertiary (Referral/ Specialized hospitals) 100 0.0 23 Total 76.1 23.9 255 Regional variations were observed in the availability of the five (including 3 essential) life-saving maternal/reproductive health medicines. Three–quarters of health service delivery points in all regions had all the five (including 3 essential) life-saving maternal/reproductive health medicines in the stock during survey time. All the five (including 3 essential) life-saving maternal/reproductive health medicines were available in all health facilities in Harari while only two-thirds (67%) health service delivery points in Dire Dawa and Gambella reported to have all the five (including 3 essential) life-saving maternal/reproductive health medicines in the stock. Table 12 shows the distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines by region. | P a g e 30 Table 12: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by region, October 2010 Region Percentage Five (including 3 essential) life- saving maternal/reproductive health medicines available Five (including 3 essential) life- saving maternal/reproductive health medicines not available Total (n) Addis Ababa 89.3 10.7 28 Afar 80.0 20.0 5 Amhara 76.5 23.5 51 Benshangul Gumuz 83.3 16.7 6 Dire Dawa 66.7 33.3 3 Gambella 66.7 33.3 3 Harari 100 0.0 5 Oromia 72.5 27.5 80 SNNP 70.8 29.2 48 Somali 80.0 20.0 5 Tigray 76.2 23.8 21 Total 76.1 23.9 255 Rural-urban residence of service delivery points is one of the factors affecting the availability of maternal/reproductive health medicines. This survey showed that five (including 3 essential) life-saving medicines were about three times more available in urban service delivery points (94%) as compared to rural service delivery points (34%). Table 13 shows the distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines by urban-rural residence. Table 13: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by urban/rural residence, October 2010 Residence Percentage Five (including 3 essential) life- saving maternal/ reproductive health medicines available Five (including 3 essential) life- saving maternal/ reproductive health medicines not available Total (n) Urban 93.9 6.1 179 Rural 34.2 65.8 76 Total 76.1 23.9 255 Health facility ownership (who owns and manages the facility) is also an important factor that determines the availability of maternal/ reproductive health medicines. The survey indicated that five (including 3 essential) life-saving maternal/ reproductive health medicines were most available in service delivery points owned and managed by NGOs (83.3%) and private sectors (89%). The five (including 3 essential) life-saving maternal/ reproductive health medicines were available in three–quarters of the service delivery points owned by government. Table 14 shows percentage distribution of service delivery points. | P a g e 31 Table 14: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by management of facility, October 2010 Management of facility Percentage Five (including 3 essential) life- saving maternal/reproductive health medicines available Five (including 3 essential) life- saving maternal/reproductive health medicines not available Total (n) Government 75.4 24.6 240 NGO 83.3 16.7 6 Private 88.9 11.1 9 Total 76.1 23.9 255 The location of service delivery points is believed to affect the availability of maternal/reproductive health medicines with more service delivery points closer to the source of supply/warehouse assumed to have more maternal/reproductive health medicines compared to those located far away. In the current survey, however, the pattern of the relationship between the availability of life-saving medicines and the distance of the service delivery points from the source of supply/warehouse seems to be reversed. With the exception of those service delivery points located below five kilometres from the nearest warehouse/source of supplies, the percentage of service delivery points where five (including 3 essential) life-saving maternal/reproductive health medicines available increases with increasing distances from the nearest warehouses. Service delivery points that are located closer to the nearest warehouses may not think of keeping these medicines at their stock for they wrongly believe that they can get the medicines from the warehouse whenever they are in need. Table 15 shows the percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by distance from nearest warehouse/source of supplies. | P a g e 32 Table 15: Percentage distribution of service delivery points with five (including 3 essential) life-saving maternal/reproductive health medicines available by distance from nearest warehouse/source of supplies, October 2010 Distance from nearest warehouse/source of supplies (in Km)) Percentage Five (including 3 essential) life- saving maternal/reproductive health medicines available Five (including 3 essential) life- saving maternal/reproductive health medicines not available Total (n) 0-4 80.5 19.5 41 5-9 35.7 64.3 28 10-14 50.0 50.0 22 15-19 53.3 46.7 15 20-24 54.5 45.5 11 25-29 66.7 33.3 3 30-35 70.0 30.0 10 35-39 83.3 16.7 6 40-45 0.0 100 1 45-49 100 0.0 5 50 and over 94.7 5.3 113 Total 76.1 23.9 255 2.3.3 Reasons for not offering certain life-saving maternal and reproductive health medicines There are different reasons why service delivery points are not offering maternal/reproductive health medicines. In this survey, reasons for not offering maternal/reproductive health medicines were identified. The main reasons for not offering Oxytocin, for example, were cited as ‘no supply’ by 33%, ‘not requested’ by 4.4% and ‘not in the facility drug list’ by 62.5% of the health service delivery points. Similarly, the main reasons for not offering Ergometrine was cited as ‘no supply’, ‘not requested', and ‘not in the facility drug list’ by 38%, 7% and 32% of the service delivery points, respectively. Significant proportion of service delivery points (13%) cited other reasons for not offering Ergometrine. The reasons for not offering Magnesium Sulfate by service delivery points were mainly due to ‘no supply’ (48.5%) or ‘not in the facility drug list’ (44%). Only 5.4% of the service delivery points mentioned ‘not requested ‘as a reason for not offering this maternal/reproductive health medicine. Table 16 shows percentage distribution of service delivery points by reasons for not offering maternal/reproductive health medicines. | P a g e 33 Table 16: Percentage distribution of service delivery points with main reasons for not offering maternal/ reproductive health medicines, October 2010 At the time of the survey, inventory of maternal/reproductive health medicines was done in all health service delivery points included in the survey. Oxytocin and Ergometrine were in stock in 81% and 71% of the service delivery points, respectively, while Magnesium Sulfate was in stock only in 17% of the service delivery points. Antibiotics (Amoxicillin, Benzathin Penicillin, Doxicyclin and Metronidazole) were in stock in 70-80% of the service delivery points. Figure 8 shows the percentage distribution of service delivery points by different maternal/reproductive health medicines available in the stock at the time of the survey. Figure 8: Percentage distribution of service delivery points maternal/ reproductive health medicines available in stock at the time of survey, October 2010 Table 17 shows the main reasons for maternal/reproductive health medicines not currently available in the stock. The most commonly cited reasons for not having sufficient maternal/reproductive health Maternal/ reproductive health medicines Reason n No supply Not requested Not in the facility drug list Other Amoxicillin 20.0 6.7 68.9 4.4 45 Azithromycine 27.9 9.6 40.6 22.2 219 Benzanthine Penicillin 19.4 19.4 55.2 4.5 67 Cefexime 26.1 6.6 51.2 15.7 211 Clotrimazole 28.4 9.0 58.2 3.0 67 Ergometrine 37.7 7.2 31.9 13.0 69 Iron/Folate 40.3 32.8 19.4 4.5 67 Magnesium Sulfate 48.5 5.4 44.1 1.0 202 Metronidazole 21.3 10.6 63.8 4.3 47 Oxytocine 33,3 4.4 48.9 4.4 45 Doxycycline 16.7 10.4 62.5 6.3 48 | P a g e 34 medicines in the stock were “no supply” (61.2%), “not in facility drug list” (58%) and “not requested” (26%). Table 17: Percentage distribution of service delivery points' reasons for not having maternal/ reproductive health medicines in the stock, October 2010 Reasons Percentage Number No supply 61.2 156 Not requested 25.9 66 Not in facility drug list 58.0 148 | P a g e 35 2.4 Incidence of ‘No Stock Out’ of Modern Contraceptives Overview: A stock-out can occur at one point in time or over a period of days, weeks or months. When there is a good stock management system in place, the stock-out duration will be minimal. Incidence of ‘No stock out’ of modern contraceptives refers to ‘the situation in which a family planning service delivery point in a country does not run out of supplies of any one or more of the modern contraceptive methods in the last/previous six months and, therefore, had supplies on hand to serve clients at all times. This survey focused on assessing availability/’no stock out’ of modern contraceptive methods (oral pills, injectables, male condoms, female condoms, implants, IUCD, female sterilization and male sterilization) in the service delivery points. In particular, the survey examined incidence of ‘stock out’ of modern contraceptive methods at the time of the survey and in the last six months prior to the survey. Reasons for stock out were also identified. 2.4.1 ‘No Stock Out’ at time of survey The findings revealed that almost all the surveyed facilities (98.8%) availed at least one type of modern contraceptive method in the stock. The mean number of modern contraceptive methods available in stock at the time of the survey was estimated at 4.5. Only 1.6% of SDPs were found fully stocked with all modern contraceptive methods, while nearly one third (31.8%) of SDPs have five of the modern contraceptive methods in their stock at the time of survey. Specifically, the findings indicated that large proportion of the facilities were stocked with oral pills (97.2%) followed by injectables (96.0%), male condoms (94.1%), implants (79.5%), IUCD (55.3%), female sterilization (21.7%), male sterilization (17.4%) and female condom (5.2%) (see Figure 9 below). Figure 9: Percentage of service delivery points with modern contraceptive methods in stock at the time of the survey, October 2010 | P a g e 36 The survey result further revealed that all tertiary SDPs, 99.4% of primary level SDPs, and 96.8% of secondary level SDPs had stocks of modern contraceptive methods at the time of survey (see Table 18 below). Table 18: Percentage distribution of service delivery points with modern contraceptive methods in stock at the time of the survey by type of facility, October 2010 Type of Facility Percentage Total (n) Modern contraceptive method in stock at the time of the survey Modern contraceptive method not in stock at the time of the survey Primary level care SDPs 99.4 0.6 169 Secondary level care SDPs 96.8 3.2 63 Tertiary level care SDPs 100.0 0.0 23 Total 98.8 1.2 255 Availability of IUCD and injectables was reported in all of the tertiary level SDPs. Male condom, oral pills and injectable were in stock in more than 95% of the surveyed SDPs at the time of the survey. Over 95% of both primary and secondary level SDPs had experienced stock out of female condoms. On the other hand, both male and female sterilization kits were found in only 3% of the primary level SDPs. As shown in Figure 10, all SDPs except those in SNNP (97.1%) and in Oromia (97.5%), were stocked with at least one type of modern contraceptive method. Female condoms were out of stock in all regions except in Amhara, SNNP and Somali at the time of the survey; whereas, male and female sterilization kits were reported out of stock in Somali Region and Dire Dawa City Administration. On the other hand, no stock out of male condom, oral pills and injectables was reported in less than half of the regions. Figure 10: Percentage of service delivery points with modern contraceptive methods in stock at the time of survey by region, October 2010 | P a g e 37 Variations were observed in availability of modern contraceptive methods between urban and rural settings. Stock out of modern contraceptives was observed in only 3.9% of the rural SDPs as opposed to no stock out among the urban facilities (Table 19). Table 19: Percentage distribution of service delivery points with modern contraceptive methods in stock at the time of the survey by urban/rural residence, October 2010 Residence Percentage Total (n) Modern contraceptive method in stock at the time of the survey Modern contraceptive method not in stock at the time of the survey Urban 100.0 0.0 179 Rural 96.1 3.9 76 Total 98.8 1.2 255 Availability of male condoms, oral pills, and injectables was reported in more than 90 % of the rural SDPs, whereas, in over 95% of these SDPs, female condom, male and female sterilization kits were out of stock. Variations in stock status were also observed with regard to ownership of SDPs surveyed. As described in Table 20, all government and NGO/mission owned SDPs had at least one type of contraceptive method in stock at the time of the survey. On the other hand, three of the six privately owned SDPs had experienced stock out of any one of the contraceptive methods. Male condoms, oral pills and implants were found in 100% of NGO/Mission owned SDPs and female condoms were not in stock in both the NGO/Mission and private SDPs. While 75% of NGO/Mission SDPs had reported availability of male and female sterilization kits, these kits were available in less than 20% and 45% of government and private SDPs, respectively. Table 20: Availability of modern contraceptive methods in stock at the time of the survey by management of facility, October 2010 Management of facility Percentage Total (n) Modern contraceptive method in stock at the time of the survey Modern contraceptive method not in stock at the time of the survey Government 100.0 0.0 240 NGO/Mission 100.0 0.0 9 Private 50.0 50.0 6 Total 98.8 1.2 255 The data presented in Table 21 shows no significant difference in availability of modern contraceptive methods among SDPs to the nearest warehouse/sources of supplies. | P a g e 38 Table 21: Availability of modern contraceptive methods in stock at the time of the survey by distance from nearest warehouse/source of supplies, October 2010 Distance from nearest warehouse/source of supplies (in Km) Percentage Total (n) Modern contraceptive method in stock at the time of the survey Modern contraceptive method not in stock at the time of the survey 0-4 100.0 0.0 41 5-9 100.0 0.0 28 10-14 100.0 0.0 22 15-19 100.0 0.0 15 20-24 100.0 0.0 11 25-29 100.0 0.0 3 30-34 100.0 0.0 10 35-39 83.3 16.7 6 40-45 100.0 0.0 1 45-49 100.0 0.0 5 50 and over 98.2 1.8 113 Total 98.8 1.2 255 2.4.2 ‘No Stock Out’ in the last six months Another indicator used to measure availability of modern contraceptive methods in SDPs is the six- month stock out rate, which is the percentage of facilities experiencing stock out of a particular product for six months prior to the survey. Among the SDPs surveyed, an overall rate of 99.2% ‘no stock out’ of modern contraceptive methods was reported. As shown in figure 11, a large proportion of SDPs reported no stock out of oral pills (94.1%) followed by injectables (89.3%), male condoms (87.7%) and implants (75.1%); whereas female condoms (6.7%), male sterilization (19.4%) and female sterilization (24.3%) were found to be scarce in these facilities. | P a g e 39 Figure 11: Percentage of service delivery points with no stock out of any modern contraceptive method in the last six months, October 2010 Great variation was observed in the duration of stock out of modern contraceptive methods that ranged from 1 to 180 days with an overall average of 121 days (about four months). Five of the eight modern contraceptive methods (female condom, male and female sterilization kits, IUCD and Implants) were found to be out of stock for about five months on the average. On the other hand, male condoms, oral pills and injectables were out of stock for less than two months. As shown in Table 22, none of the primary and tertiary level SDPs had stock out of any of the contraceptive methods in the last six months prior to the survey; whereas, only 3.2% of secondary level SDPs experienced stock out. Analysis of stock out status of individual contraceptive methods against type of facility revealed that none of the tertiary level SDPs had stock out of oral pills and injectables. In contrast, over 90% of primary level care SDPs reported stock out of female condom (94.6%), male sterilization kits (94.0%), and female sterilization kits (92.2%). Table 22: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by type of facility, October 2010 Type of Facility Percentage No stock out of modern contraceptive method in the last six months Stock out of modern contraceptive method in the last six months Total (n) Primary (health post & health centre) 100 0.0 169 Secondary (rural, zonal & regional) hospitals) 96.8 3.2 63 Tertiary (referral/specialized hospitals) 100 0.0 23 Total 99.2 0.8 255 | P a g e 40 Findings presented in Table 23 show no remarkable regional variation was observed in the stock status of modern contraceptive methods. Table 23: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by Region, October 2010 Region Percentage No stock out of modern contraceptive method in the last six months Stock out of modern contraceptive method in the last six months Total (n) Addis Ababa 100 0.0 28 Afar 100 0.0 5 Amhara 100 0.0 51 Benshangul Gumuz 100 0.0 6 Dire Dawa 100 0.0 3 Gambella 100 0.0 3 Harari 100 0.0 5 Oromia 98.8 1.2 80 SNNP 97.9 2.1 48 Somali 100 0.0 5 Tigray 100 0.0 21 Total 99.2 0.8 255 Regarding urban-rural stock status, only 2.6% of rural SDPs had stock out of at least one of the modern contraceptive methods in the last six months prior to the survey. Table 24: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by urban/rural residence, October 2010 Residence Percentage No stock out of modern contraceptive method in the last six months Stock out of modern contraceptive method in the last six months Total Urban 100 0.0 179 Rural 97.4 2.6 76 Total 99.2 0.8 255 As shown in Table 25, all of the surveyed government and private owned SDPs had no stock of at least one type of modern contraceptive method in the last six months prior to the survey. On the other hand, four of the six surveyed NGO/Mission owned SDPs reported no stock out in the period specified. | P a g e 41 Table 25: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by management of facility, October 2010 Management of facility Percentage No stock out of modern contraceptive method in the last six months Stock out of modern contraceptive method in the last six months Total Government 100 0.0 240 NGO/Mission 66.7 33.3 6 Private 100 0.0 9 Total 99.2 0.8 255 Table 26 shows percentage distribution of SDPs with ‘no stock out ‘of modern contraceptive methods in the last six months by distance from nearest warehouse/source of supplies. Accordingly, 1.8% of SDPs that were far from the nearest warehouse/ source of supplies by 50 and more kilometres experienced stock out of modern contraceptive methods in the last six months prior to the survey. Table 26: Percentage distribution of service delivery points with no stock out of a modern contraceptive method in the last six months by distance from nearest warehouse/source of supplies, October 2010 Distance from nearest warehouse/source of supplies (in Km) Percentage No stock out of modern contraceptive method in the last six months Stock out of modern contraceptive method in the last six months Total (n) 0-4 100 0.0 41 5-9 100 0.0 28 10-14 100 0.0 22 15-19 100 0.0 15 20-24 100 0.0 11 25-29 100 0.0 3 30-34 100 0.0 10 35-39 100 0.0 6 40-45 100 0.0 1 45-49 100 0.0 5 50 and over 98.2 1.8 113 Total 99.2 0.8 255 2.4.3 Reasons for ‘stock out’ One of the major challenges to effective provision of family planning services has been persistent stock- outs of contraceptives and other reproductive health supplies. Stock out is a chronic concern that affects continued use of modern contraceptive methods and quality of services. Although the rates of ‘stock out’ both at the time of survey and in the last six months prior to the survey seem to be insignificant, stock out analysis of individual contraceptive methods revealed that some methods such as female condoms, male and female sterilization kits and IUCDs were out of stock in most of the surveyed SDPs. The most frequently cited reasons for stock out were attributed to logistics management (shortage of | P a g e 42 supply, delay in delivery, delay in order placement and inadequate budget), SDP specific drug list standards, lack of trained personnel and product expiry. Shortage of supply was mentioned by the great majority of surveyed SDPs as one of the major reasons for stock out of modern contraceptive methods. Injectables, female condoms, and male condoms were out of stock in 77.8%, 61.9%, and 60.0% of SDPs, respectively, due to shortage of supply. Similarly, supply problem accounted for 73.9% and 66.7% of SDPs for stock out of female condoms and injectables, respectively, in the last six months prior to the survey. About 44.0% of SDPs had stock out of oral pills both at the time of survey and in the six months period due to supply problem. ‘No-request’ for supplies was also reported as one of the reasons for stock out. Some 42.9%, 20.0% and 11.9% SDPs had out of stock of oral pills, male condoms and injectables, respectively, because of failure to put order for refill. Delay in delivery of supply from the source was reported as another contributing factor for stock out of modern contraceptive methods at SDPs. Hence, delay in supply was reported for stock out of oral pills, male condoms, and injectables in 18.8%, 16.1% and 14.8% of SDPs, respectively, in the last six months prior to the survey. Also, 7.4% and 3.2% of the SDPs reported lack of transportation as a reason for stock out of injectables and male condoms, respectively, in the period specified. Modern contraceptive methods are provided based on the national drug list standards specific to each level of SDP. Hence, IUCD, female and male sterilization were reported as out of stock as a result of unavailability of these services in the facilities. Absence of trained health practitioners to provide services of IUCD insertion, female and male sterilization, and implant accounted for 55.0%, 52.3%, 51.9% and 42.6% of SDPs, respectively, as causes of stock out at the time of the survey. Similarly, female and male sterilization services were not available in 45.6% and 38.8% of SDPs, respectively, due to absence of trained health practitioners. Product expiry of male condoms, oral pills, injectables, and implants was reported as the other cause for stock out in 19.4%, 12.5%, 11.1%, 1.8% and 1.6% of the SDPs, respectively, at the time of survey and in the last six months prior to the survey. Besides, unavailability of equipment to provide female and male sterilization was reported in 9.3% and 11.7% of SDPs, respectively, as reason for not accessing the services. Table 27 below summarizes percentage of SDPs for stock out of modern contraceptive methods. 43 | P a g e Table 27: Reasons for stock out of modern contraceptive methods, October 2010 Contraceptive Method No supply Not requested Delay from supply source Lack of transport Not in the facility drug list Expired No trained personnel Shortage of budget No demand Equipment not available Others n Male Condoms 60.0 20.0 16.1 3.2 - 13.3 6.7 3.2 - - 6.5 15 Female Condoms 61.9 25.0 - - 2.3 0.4 10.0 1.3 22.6 - 6.3 239 Oral Pills 43.8 42.9 18.8 14.3 - - - - - 7 Injectables 77.8 11.1 14.8 7.4 - 11.1 - - - - 3.7 9 IUDs 29.7 2.7 0.9 - 10.8 10.3 55.0 - - - 45.8 111 Implants 39.7 3.3 1.6 - 14.8 1.6 42.6 - - - 41.3 61 Sterilization for Females 2.0 1.6 - - 39.4 - 52.3 - 3.6 9.3 2.6 197 Sterilization for Males 9.1 6.3 - - 27.9 - 51.9 - 6.3 11.7 12.1 208 44 | P a g e SECTION III: CONCLUSION 3.1 Summary of Findings Ensuring the availability of life-saving maternal/reproductive health medicines in health service delivery points is one of the important tasks policy makers and program managers need to consider in the design of appropriate intervention strategies toward reducing maternal mortality and achieving MDG 5. There are little or no large scale studies done to determine the availability of modern contraceptives and life- saving maternal/reproductive health medicines in health facilities in Ethiopia. This survey was, therefore, conducted to assess the availability of modern contraceptives and maternal/reproductive health medicines at the service delivery points in Ethiopia. The survey revealed that family planning services, in most cases, mal-functioned from lack of or erratic supply of modern contraceptive methods. Though the Government has given emphasis to reducing maternal and child mortality through scaling-up reproductive health services at the grassroots level, health posts and other service delivery points are challenged by poor supply of modern contraceptive methods. Lack of trained personnel has further aggravated the situation. Not all of the health posts, health centres and even regional hospitals (at secondary level) offer at least three types of modern contraceptive methods. Female condoms, male and female sterilization, and IUDs remained scarce in most service delivery points. Even tertiary level SDPs are not serving fully the community with temporary modern contraceptive methods like male condoms, and long acting methods like IUDs, implants, female and male sterilization. Though maternal/reproductive health medicines were less available in most service delivery points, the situation is worse in primary level service delivery points (health posts and health centres). Compared to other maternal/reproductive health services, essential life-saving maternal/reproductive health medicines are less available in most service delivery points. Availability of maternal/reproductive health medicines at service delivery points is influenced by factors such as type of health facility, the region in which the service delivery is located, urban-rural residence, and facility ownership/management. However, distance of the SDPs from the nearest warehouse/source of supplies was not found the major factor affecting availability of the medicines. Stock out indicators measure product availability over a period of time, and serve as proxy indicators of the ability of a program to meet clients’ needs with a full range of products and services. It is highly plausible that better systems and increased product availability enable increased use and improved health outcomes. Product availability is the most vital logistics result from the clients’ perspective and may be the most important parameter to ensure sustainable family planning services. Findings of this survey showed improvements in availability of modern contraceptive methods at the SDPs compared to the previous findings. [6,16] The observed high magnitude of ‘no stock out’ of modern contraceptive methods at SDPs implies a promising progress towards achieving the country’s target of 100% ‘no stock out’ by the year 2012. [6] In this survey, substantial improvement (99.2%) on overall ‘no stock out’ situation of modern contraceptive methods in the last six months was observed as opposed to 60% in 2006 and 90% in 2009. [6] The proportion of ‘no stock out’ at the time of the survey and in the last six months before the survey has also shown marked increase on some of the 45 | P a g e contraceptive methods as compared to the 2006 survey using the Logistics Indicator Assessment Tool (LIAT). [16] Accordingly, percentage of SDPs stocked out of contraceptive methods any time in the last six months prior to the survey had shown reduction from 20.2% to 12.3% for male condoms; 58.7% to 10.7% for Injectables; 62.9% to 24.9% for implants and 30.2% to 5.9% for oral pills. Similar reduction in percentage of SDPs stocked out at the time of the survey was observed: male condoms (from 12.1% to 6.0%), injectables (from 24.6% to 5.6%), implants (from 51.4% to 24.6%), and oral pills (from 15.5% to 2.8%). In contrast, the proportion of SDPs, which were stocked out of IUD and female condoms both at the time of the survey and in the last six months prior to the survey, have shown increase over the findings of 2006. [16] The survey data on reasons of stock out (no supply, not requested, no transportation, no trained provider and equipment not available) augmented the challenges of stock out and needs special attention in the process of expanding services and securing availability of a wide range of modern contraceptive methods. High percentage of female condoms available in stock is 20% in Somali Region. However, zero stock of female condoms (both at the time of the survey and in the last six months prior to the survey) was reported in many of the regions except Amhara, Oromia, and SNNP. Besides the reasons reported as causes for stock out of female condom (no demand, not requested, etc.), there remains a need for investigating both the cultural influence and health providers’ involvement to promote and encourage their clients. In addition, the stock status of female and male sterilization kits in many of the regions requires due attention. 3.2 Recommendations The survey presented an encouraging picture that Ethiopia is in a promising position in implementing national strategies “to implement more sustainable approach to RHCS” to reach ‘no stock out’ of modern contraceptive method/products at SDPs by 2012. Based on findings of this survey, syntheses of recommendations are presented as follows: • The Federal MOH, regional health bureaus, zonal health departments and woreda health offices should make concerted efforts to avail at least one form of family planning service at all levels and to ensure that all SDPs must provide at least normal child service delivery to curtail maternal mortality caused by unskilled deliveries. • Ensuring method choice at all service delivery points is crucial to reducing maternal and child mortality in relation to risks associated with unwanted pregnancy. Thus, all temporary contraceptive methods (male and female condoms, oral pills and injectables) should be available at all service delivery points irrespective of facility tier system. In addition, long-acting (IUDs, implants) and permanent methods (male and female sterilizations) should be available at all secondary and tertiary levels and health centres. • Ideally, all family planning services should be accessible to clients at their localities. The Government of Ethiopia and its partners should further expand service delivery points and maintain the existing ones to improve and ensure continuity of quality of services at all levels. 46 | P a g e • Family planning (FP) providers must be viewed as critical factors to optimize acceptability, uptake, and continued use of modern contraceptive methods. • Logistics system should be strengthened to coordinate sustainable supply of modern contraceptive methods to all levels of SDPs. • Male and female condoms, IUDs and implants were not offered in some facilities as they were never requested. Therefore, facility directors/managers, regional health bureaus, zonal and woreda health offices should be responsible for the follow-up and monitoring of timely requests and forecasts of modern contraceptives. • Building the capacity of health workers at the service delivery points is essential as it was reflected in this survey. There should be proper planning of basic and refresher training for these professionals on family planning; particularly on long-acting and permanent methods as more than half of the facilities mentioned lack trained personnel to offer modern contraceptives. • About 11% of the facilities do not offer male and female sterilization due to lack of equipment. Therefore, the FMOH should work towards equipping both secondary and tertiary level SDPs to provide permanent family planning services. • First level service delivery points are the first choice of mothers to obtain reproductive health services including child delivery services. Thus, availing essential maternal/reproductive health medicines at the primary level of SDPs (health posts and health centres) remains critical to decrease maternal mortality. • Efforts should be made by the FMOH and all stakeholders to ensure the availability of maternal/reproductive health medicines in all health facilities in general and essential life- saving maternal/reproductive health medicines in particular. • The Federal Ministry of Health and regional health bureaus must allocate budget for FP commodities and maternal health medicines and ensure that a budget line is created at all levels. • The supply chain management systems should be strengthened to avail FP commodities and life saving maternal medicines to the end users at all times. • Stock out is one of the critical barriers to contraceptive access. It can be reduced by: o Improving functioning logistics system (avoid delay in order processing, improve availability and supply of modern contraceptive methods at central warehouse) 47 | P a g e o Reducing average duration of stock outs for all products (minimizing expiry of all products through continuous stock tracking and re-distribution mechanisms). o Increasing the number of skilled personnel for the management of supplies and delivery of services. o Providing in-service training to health providers on family planning methods, stock and inventory management principles, customer handling and skills to practice specific methods such as IUCD insertion, implant administration, etc. o Maintaining effective monitoring and evaluation system for tracking the results of interventions and for deriving lessons learned to be used in guiding program implementation. 48 | P a g e SECTION IV: REFERENCES 1. CSA and ORC Macro, Ethiopia Demographic and Health Survey 2005. Addis Ababa, Ethiopia and Calverton, Maryland, USA, 2006. 2. FMOH, National Baseline Assessment for Emergency Obstetric & Newborn Care, Ethiopia, 2008. 3. USAID and WHO, Family Planning, A Global Handbook for Providers, 2007. 4. PATH, WHO, and UNFPA. Essential Medicines for Reproductive Health: Guiding Principles for their inclusion on National Medicines Lists. Seattle: PATH; 2006. 5. UNFPA, Recent Success Stories in Reproductive Health Commodity Security, New York, 2010. 6. UNFPA, RHCS Update: The Global Program to enhance Reproductive Health Commodity Security, New York, 2010. 7. Cates Jr W. Family Planning; The Essential Link to Achieving All Eight Millennium Development Goals, Contraception 2010; 81(6):460-61. 8. Population Action International, Reproductive Health Supplies Coalition, Advocacy Guide; Empty handed responding to the demand for contraceptives. Available at www.rhsupplies.org. 9. Laurus Nobilis, Stock out Measurement (I), Nov, 2009. Available at http://www.biz- development.com/SupplyChain/6.18.Stock-Out-Measurement.htm. 10. FMOH, Planning and Programming Directorate, Health and Health related Indicators, 2009/10. 11. FMOH, Health Extension Program in Ethiopia, PROFILE, Addis Ababa, 2005. 12. Federal Democratic Republic of Ethiopia (FDRE), Policies and Strategies, Addis Ababa, Ethiopia 2009. 13. Tsedeke Tuloro et al., The Role of Men in Contraceptive Use and Fertility Preference in Hossaena Town, Southern Ethiopia, Ethiopian Journal of Health Development, 2006; 20(3): 152-159. 14. UNFPA, Poverty Card – Ethiopia, www.unfpa.org/webdav/site/./unfpa_povertycard_eth_en.pdf; accessed 3rd December 2010. 15. FMOH and EHNRI, Commodity Tracking and Stock Management Study Report, Addis Ababa, Ethiopia, October 2009. 16. FMOH, Family Health Department, Contraceptive Inventory and Logistics System Survey, January 2006. 49 | P a g e SECTION V: ANNEXES Annex A: Survey Questionnaire AVAILABILITY OF MODERN CONTRACEPTIVES AND ESSENTIAL LIFE SAVING MATERNAL/RH MEDICINES IN SERVICE DELIVERY POINTS IN ETHIOPIA INFORMATION ABOUT THE INTERVIEW Country ……………………………………………………………………………………….…………………………………………………………… Date of the Survey (year and month) ………………………………………….……………………………………………….…………… Name of Interviewer ………………………………………………………………………………………………………………………………… Date of Interview……………………………………………………………………………………………………………………………………… Questionnaire checked and attested to be properly completed Name of Supervisor………………………………………………………………………………………….……………………………………….…. Signature ……………………………………………………… Date ……………………………………………….…… 50 | P a g e NAME, LOCATION AND DISTANCE SN O ITEMS 001 Name of Service Delivery Point…………………………………………………………….……….…….……………… 002 A) Location: Region __________ Zone _____________ Woreda ______________Kebele _________________________ B) Please indicate whether the SDP is located in an urban area or a rural settlement (as per your country’s classification; 1 Urban 2 Rural 003 A) What is the distance between the location of the health facility and the nearest warehouse or store or facility where health supplies are stored and from which this health facility receives its regular supplies? /____/ B) Please indicate distance in; 1 Kilometres 2 Mile SDP TYPE AND SERVICES PROVIDED 004 Type of Service Delivery Point (Tick the option that is applicable to your country) 1 Health post 4. Zonal hospital 7. Other (please specify) ____________________________ 2 Health centre 5. Regional hospital 3 Rural hospital 6. Referral/specialized hospital 005 Management of Service Delivery Point: 1 Government 2 Private 3 NGO 4 Others (please specify…………………………) 006 Does this facility provide family planning services? 1 Yes 2 No (If No, then items 009, 010 and; 013 to 017 should NOT be administered) 007 Does this facility provide delivery services? 1 Yes 2 No (If No, then items 011 and 012 should NOT be administered) 008 Does this facility provide any HIV/AIDS services (e.g. VCT, PMTCT, ART, PICT, etc.)? 1 Yes 2 No MODERN CONTRACEPTIVE METHODS PROVIDED AT SDP Item Male condoms Female Condoms Oral Pills Injectables IUDs Implants Sterilisation for Females Sterilisation for Male 009: For each of the contraceptives, please state whether it is provided to clients at this Service Delivery Point. 1 Yes 2 No (circle only one option) 1 Yes 2 No (circle only one option) 1 Yes 2 No (circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 010: If the contraceptive method is NOT provided to clients at this service delivery point, please indicate the reason. 51 | P a g e AVAILABILITY OF MATERNAL/RH MEDICINES Item Maternal/RH Medicines Amoxicillin Azithromycine Benzathine Penicillin Cefexime Clotrimazole Ergometrine Iron/Folate Magnesium Sulfate Metronidazole Oxytocine Doxy 011: For each of the maternal/RH medicines please indicate whether it is currently available in this health facility. 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 012: If the medicine is not currently available in this health facility, please indicate the reasons. INTERVIEWER VERIFICATION for ITEM 010 For each response provided for item 011, the interviewer should validate the response by a physical Inventory and note the appropriate finding. 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1 Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory taken, Medicine is in stock 2. Inventory taken, Medicine is NOT in stock 1. Inventory take Medicine is in stock 2. Inventory take Medicine is NOT stock 52 | P a g e NO STOCK OUT OF MODERN CONTRACEPTIVE METHODS AT SDP Item Male condoms Oral Pills IUDs Implants Injectables Female Condoms Sterilisation for Male Sterilisation for Females 013) For each of the contraceptive methods please indicate whether it is currently in stock in this health facility. 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 014) If the contraceptive method is not currently in stock at this health facility, please indicate the reason. 015) For each of the contraceptive methods please indicate whether it has been out of stock at this health facility at any given day, in the last six months preceding the survey, and therefore unavailable to give to clients at that time. 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 1 Yes 2 No (Circle only one option) 016) If yes, please indicate the number of days the contraceptive method was out of stock in your health facility in the last six months preceding the survey. ……………………. ……………………. ……………………. ……………………. ……………………. ……………………. ……………………. ……………………. 017) If the contraceptive method was out of stock at any given time at this health facility, in the last six months, please indicate the reason. For each response provided for item 013, the interviewer should validate the response by a physical inventory and note the appropriate finding. 1. Inventory taken, contraceptive is in stock 2. Inventory taken, contraceptive is NOT in stock 1.Inventory taken, contraceptive is in stock 2. Inventory taken, contraceptive is NOT in stock 1.Inventory taken, contraceptive is in stock 2. Inventory taken, contraceptive is NOT in stock 1.Inventory taken, contraceptive is in stock 2. Inventory taken, contraceptive is NOT in stock 1.Inventory taken, contraceptive is in stock 2. Inventory taken, contraceptive is NOT in stock 1.Inventory taken, contraceptive is in stock 2. Inventory taken, contraceptive is NOT in stock 1.Inventory taken, contraceptive is in stock 2. Inventory taken, contraceptive is NOT in stock 1.Inventory taken, contraceptive is in stock 2. Inventory taken, contraceptive is NOT in stock 53 | P a g e Annex B: List of service delivery points surveyed No. SDP Name Type of Facility Region 1 BRASS MCH HOSPITAL Health centre Addis Ababa 2 BOLE HEALTH CENTRE Health centre Addis Ababa 3 BOLE 17/20 HEALTH CENTRE Health centre Addis Ababa 4 KALITI HEALTH CENTRE Health centre Addis Ababa 5 MARIE INTERNATIONAL (KIRKOS) CLINIC Health centre Addis Ababa 6 NIFAS SILK LAFTO NO 1 HEALTH CENTRE Health centre Addis Ababa 7 MESHUALKIA HEALTH CENTRE Health centre Addis Ababa 8 NIFAS SILK LAFTO K/K NO2 Health centre Addis Ababa 9 ARADA HEALTH CENTRE Health centre Addis Ababa 10 KOLFE HEALTH CENTRE Health centre Addis Ababa 11 GULELE HEALTH CENTRE Health centre Addis Ababa 12 KOTEBE HEALTH CENTRE Health centre Addis Ababa 13 ANAMIYA MATERNAL & CHILD HEALTH Health centre Addis Ababa 14 TEKLE HAIMANOT HEALTH CENTRE Health centre Addis Ababa 15 KAZANCHIS HEALTH CENTRE Health centre Addis Ababa 16 BELETSHIACHEW HEALTH CENTRE Health centre Addis Ababa 17 WOREDA 7 HEALTH CENTRE Health centre Addis Ababa 18 ADDIS KETMA HEALTH CENTRE Health centre Addis Ababa 19 GANDI MEMORIAL HOSPITAL Referal/Specialized hospital Addis Ababa 20 YEKATIT 12 HOSPITAL Referal/Specialized hospital Addis Ababa 21 ADDIS MATERNITY & CHILDREN HOSPITAL Referal/Specialized hospital Addis Ababa 22 FEDERAL POLICE REFERRAL HOSPITAL Referal/Specialized hospital Addis Ababa 23 KIDUS PAULOS HOSPITAL Referal/Specialized hospital Addis Ababa 24 TIKUR ANBESA SPECIALIZED HOSPITAL Referal/Specialized hospital Addis Ababa 25 KADISO GENERAL HOSPITAL Regional hospital Addis Ababa 26 HAYAT GENERAL HOSPITAL Regional hospital Addis Ababa 27 ASEGEDECH MCH HOSPITAL Regional hospital Addis Ababa 28 DINBERUA MATERNAL AND CHILD HOSPITAL Regional hospital Addis Ababa 29 SEMERA HEALTH CENTRE Health centre Afar 30 AWASH HEALTH CENTRE Health centre Afar 31 DUBTI HEALTH POST Health post Afar 32 DUBTI REGIONAL HOSPITAL Regional hospital Afar 33 NATIONAL DISTRICT HOSPITAL Rural hospital Afar 34 WALIDYA HEALTH CENTRE Health centre Amhara 35 MERSE HEALTH CENTRE Health centre Amhara 36 HAMUSIT HEALTH CENTRE Health centre Amhara 36 HAIK HEALTH CENTRE Health centre Amhara 37 WUCHALE HEALTH CENTRE Health centre Amhara 38 KELELA HEALTH CENTRE Health centre Amhara 54 | P a g e No. SDP Name Type of Facility Region 39 GEMBA HEALTH CENTRE Health centre Amhara 40 GOREBELA HEALTH CENTRE Health centre Amhara 41 KOMBOLCHA HEALTH CENTRE Health centre Amhara 42 SENBETE HEALTH CENTRE Health centre Amhara 43 SHEWAROBIT HEALTH CENTRE Health centre Amhara 44 DEBRE BERHAN HEALTH CENTRE Health centre Amhara 45 KEYIT HEALTH CENTRE Health centre Amhara 46 INJIBARA HEALTH CENTRE Health centre Amhara 47 DURBETE HEALTH CENTRE Health centre Amhara 48 AMANUEL HEALTH CENTRE Health centre Amhara 49 0MERAW HEALTH CENTRE Health centre Amhara 50 DEMBECHA HEALTH CENTRE Health centre Amhara 51 BAHIR DAR HEALTH CENTRE Health centre Amhara 52 MERTO LEMARIAM HEALTH CENTRE Health centre Amhara 53 DELGI HEALTH CENTRE Health centre Amhara 54 GONDER HEALTH CENTRE Health centre Amhara 55 ENTRANYE HEALTH CENTRE Health centre Amhara 56 GONDER UNIVERSITY Health centre Amhara 57 ADDIS ZEMEN HEALTH CENTRE Health centre Amhara 58 CHEFE HEALTH POST Health post Amhara 59 DOBLE MARIAM HEALTH POST Health post Amhara 60 TISSA HEALTH POST Health post Amhara 61 MITAK HEALTH POST Health post Amhara 62 CHORISSA HEALTH POST Health post Amhara 63 GERBI HEALTH POST Health post Amhara 64 YINESA HEALTH POST Health post Amhara 65 YETNORA HEALTH POST Health post Amhara 66 CHEMO WEGA KEBELE (07) HEALTH POST Health post Amhara 67 MAYNET HEALTH POST (FARTA WOREDA) Health post Amhara 68 BELAGET DABARKA HEALTH POST Health post Amhara 69 AWZET HEALTH POST Health post Amhara 70 DESSIE HOSPITAL Referal/Specialized hospital Amhara 71 DEBRE BIRHAN REFERRAL HOSPITAL Referal/Specialized hospital Amhara 72 DEBRE MARKOS REGIONAL HOSPITAL Referal/Specialized hospital Amhara 73 FELEGE HIWOT REFERRAL HOSPITAL Referal/Specialized hospital Amhara 74 GONDER REFERAL HOSPITAL(GONDER UNIVERSITY HOSPITAL) Referal/Specialized hospital Amhara 75 TEFERA HAILUS MEMORIAL HOSPITAL Rural hospital Amhara 76 HIDAR 11 HOSPITAL Rural hospital Amhara 77 BOROMEDA HOSPITAL Rural hospital Amhara 78 FINOTESELAM HOSPITAL Rural hospital Amhara 55 | P a g e No. SDP Name Type of Facility Region 79 SHEGAW MOTTA RURAL HOSPITAL Rural hospital Amhara 80 DEBARK DISTRICT HOSPITAL Rural hospital Amhara 81 MELEMA DISTRICT HOSPITAL Rural hospital Amhara 82 WOLDIYA HOSPITAL Zonal hospital Amhara 83 DEBRE TABOR ZONAL HOSPITAL Zonal hospital Amhara 84 KAMASHI HEALTH CENTRE Health centre Benshangul Gumuz 85 FELGE SELAM HEALTH CENTRE Health centre Benshangul Gumuz 86 ASSOSA HEALTH CENTRE Health centre Benshangul Gumuz 87 KETENA 2 MENDER 131 HEALTH POST Health post Benshangul Gumuz 88 ASOSA HOSPITAL Regional hospital Benshangul Gumuz 89 PAWE HOSPITAL Zonal hospital Benshangul Gumuz 90 LEGEHARE HEALTH CENTRE Health centre Dire Dawa 91 MUDI ANANA HEALTH POST Health post Dire Dawa 92 DILCHORA HOSPITAL Referal/Specialized hospital Dire Dawa 93 ETANG HEALTH CENTRE Health centre Gambella 94 ABO HEALTH POST Health post Gambella 95 GAMBELLA HOSPITAL Regional hospital Gambella 96 ERER HEALTH CENTRE Health centre Harari 97 HARAR JEGOL HOSPITAL Referal/Specialized hospital Harari 98 SOUTH EAST ARMY HOSPITAL Referal/Specialized hospital Harari 99 HIWOT FANA HOSPITAL Referal/Specialized hospital Harari 100 HARAR POLICE HOSPITAL Regional hospital Harari 101 SHENO HEALTH CENTRE Health centre Oromia 102 SIRETIC HEALTH CENTRE Health centre Oromia 103 CHANCHO HEALTH CENTRE Health centre Oromia 104 GINDO AMEYA HEALTH CENTRE Health centre Oromia 105 WOLISO HEALTH CENTRE Health centre Oromia 106 DEMBI DOLO HEALTH CENTRE Health centre Oromia 107 TULU WAYU HEALTH CENTRE Health centre Oromia 108 ARJO HEALTH CENTRE Health centre Oromia 109 GIMBI HEALTH CENTRE Health centre Oromia 110 KERSA HEALTH CENTRE Health centre Oromia 111 ASELA HEALTH CENTRE Health centre Oromia 112 ITEYA HEALTH CENTRE Health centre Oromia 113 MOJO HEALTH CENTRE Health centre Oromia 114 BARED HEALTH CENTRE Health centre Oromia 115 ROBE HEALTH CENTRE Health centre Oromia 116 DUKEM HEALTH CENTRE Health centre Oromia 117 MEGA HEALTH CENTRE Health centre Oromia 118 ABAYA HEALTH CENTRE Health centre Oromia 56 | P a g e No. SDP Name Type of Facility Region 119 DIDEM PRIMARY HEALTH CARE Health centre Oromia 120 BULE HORA HEALTH CENTRE Health centre Oromia 121 HIGHER 2 HEALTH CENTRE Health centre Oromia 122 BATU HEALTH CENTRE Health centre Oromia 123 EJERE HEALTH CENTRE Health centre Oromia 124 KARAMILE HEALTH CENTRE Health centre Oromia 125 ADAMA HEALTH CENTRE Health centre Oromia 126 KUNNI HEALTH CENTRE Health centre Oromia 127 SHEBE HEALTH CENTRE Health centre Oromia 128 ATANGO HEALTH CENTRE Health centre Oromia 129 YAYO HEALTH CENTRE Health centre Oromia 130 BEDELE HEALTH CENTRE Health centre Oromia 131 DUGA (DARIMU ) HEALTH CENTRE Health centre Oromia 132 KOMBLCHA HEALTH CENTRE Health centre Oromia 133 BADESSA HEALTH CENTRE Health centre Oromia 134 AWASO HEALTH POST Health post Oromia 135 MOYE GAJO HEALTH POST Health post Oromia 136 KORA HEALTH POST Health post Oromia 137 AWUMER HEALTH POST Health post Oromia 138 BITATA HEALTH POST Health post Oromia 139 KILTU JELE HEALTH POST Health post Oromia 140 ABAJARA HEALTH POST Health post Oromia 141 LAKO HEALTH POST Health post Oromia 142 ZALO HEALTH POST Health post Oromia 143 ASHENA HEALTH POST Health post Oromia 144 BILALO HEALTH POST Health post Oromia 145 HALE ANDODE HEALTH POST Health post Oromia 146 ALECHA AREBATIE HEALTH POST Health post Oromia 147 ANO KERE HEALTH POST Health post Oromia 148 GOLAWACHU HEALTH POST Health post Oromia 149 DIRE KARA HEALTH POST Health post Oromia 150 SOMBOMANA HEALTH POST Health post Oromia 151 KODOHIRI HEALTH POST Health post Oromia 152 JAWIS HEALTH POST Health post Oromia 153 BRINDA HEALTH POST Health post Oromia 154 NEKEMTE HOSPITAL Referral/Specialized hospital Oromia 155 ASELA HOSPITAL Referral/Specialized hospital Oromia 156 ADAMA SPECIALIZED HOSPITAL Referral/Specialized hospital Oromia 157 METU KARL REGIONAL HOSPITAL Referral/Specialized hospital Oromia 158 JIMMA UNIVERSITY SPECIALIZED HOSPITAL Referral/Specialized hospital Oromia 57 | P a g e No. SDP Name Type of Facility Region 159 GAMBO GENERAL RURAL HOSPITAL Regional hospital Oromia 160 SHASHEMENE GENERAL HOSPITAL Regional hospital Oromia 161 NEJO HOSPITAL Rural hospital Oromia 162 AIRA HOSPITAL Rural hospital Oromia 163 GIMBI ADVENTIST HOSPITAL Rural hospital Oromia 164 DODOLA HOSPITAL Rural hospital Oromia 165 GINDEBERET HOSPITAL Rural hospital Oromia 166 DEDER HOSPITAL Rural hospital Oromia 167 LIMMU GENET HOSPITAL Rural hospital Oromia 168 AMBO HOSPITAL Zonal hospital Oromia 169 BISIDIMO HOSPITAL Zonal hospital Oromia 170 NEGELE BORENA HOSPITAL Zonal hospital Oromia 171 DEMBIDOLO HOSPITAL Zonal hospital Oromia 172 SHAMBU HOSPITAL Zonal hospital Oromia 173 GOBA HOSPITAL Zonal hospital Oromia 174 GINIR ZONAL HOSPITAL Zonal hospital Oromia 175 BISHOFTU HOSPITAL Zonal hospital Oromia 176 YABELLO HOSPITAL Zonal hospital Oromia 177 BULE HORA HOSPITAL Zonal hospital Oromia 178 FICHE HOSPITAL Zonal hospital Oromia 179 GELEMSO HOSPITAL Zonal hospital Oromia 180 CHIRO ZONAL HOSPITAL Zonal hospital Oromia 181 GARSA HEALTH CENTRE Health centre SNNP 182 LANTE HEALTH CENTRE Health centre SNNP 183 BEDESSA HEALTH CENTRE Health centre SNNP 184 BOLE HEALTH CENTRE Health centre SNNP 185 HADARO HEALTH CENTRE Health centre SNNP 186 JINKA MILLENIUM HEALTH CENTRE Health centre SNNP 187 YINA HEALTH CENTRE Health centre SNNP 188 DECA HEALTH CENTRE Health centre SNNP 189 BITA HEALTH CENTRE Health centre SNNP 190 SHISHINDA HEALTH CENTRE Health centre SNNP 191 SHEKO HEALTH CENTRE Health centre SNNP 192 TOCHA HEALTH CENTRE Health centre SNNP 193 HOMECHO HEALTH CENTRE Health centre SNNP 194 DOESHA HEALTH CENTRE Health centre SNNP 195 ARSHO HEALTH CENTRE Health centre SNNP 196 MUGO HEALTH CENTRE Health centre SNNP 197 ENDIBIR HEALTH CENTRE Health centre SNNP 198 HWARIAT HEALTH CENTRE Health centre SNNP 58 | P a g e No. SDP Name Type of Facility Region 199 YAYIE HEALTH CENTRE Health centre SNNP 200 ALETA WONDO HEALTH CENTRE Health centre SNNP 201 TEFERI KILA HEALTH CENTRE Health centre SNNP 202 ADADO HEALTH CENTRE Health centre SNNP 203 DARARA HEALTH CENTRE Health centre SNNP 204 TURGA HEALTH POST Health post SNNP 205 AMETESEDO HEALTH CENTRE Health post SNNP 206 KEYESA HEALTH POST Health post SNNP 207 GOLE HEALTH POST Health post SNNP 208 ELE HEALTH POST Health post SNNP 209 NEKIRY HEALTH POST Health post SNNP 210 SHASHO HEALTH POST Health post SNNP 211 WERABE SHAMA HEALTH POST Health post SNNP 212 HASIE HARO HEALTH POST Health post SNNP 213 AWDA HEALTH POST Health post SNNP 214 YIRGALEM HOSPITAL Referral/Specialized hospital SNNP 215 HAWASA REFERRAL HOSPITAL Referral/Specialized hospital SNNP 216 DILLA UNIVERSITY REFERRAL HOSPITAL Regional hospital SNNP 217 CHENCHA HOSPITAL Rural hospital SNNP 218 SAWAL HOSPITAL Rural hospital SNNP 219 GIDOLE DISTRICT HOSPITAL Rural hospital SNNP 220 DURAME HOSPITAL Rural hospital SNNP 221 ATAT HOSPITAL Rural hospital SNNP 222 TERCHA DISTRICT HOSPITAL Rural hospital SNNP 223 BONA DISTRICT HOSPITAL Rural hospital SNNP 224 ARBA MINCH HOSPITAL Zonal hospital SNNP 225 WOLAITA SODO HOSPITAL Zonal hospital SNNP 226 JINKA ZONAL HOSPITAL Zonal hospital SNNP 227 MIZAN AMAN GENERAL HOSPITAL Zonal hospital SNNP 228 BUTAJIRA ZONAL HOSPITAL Zonal hospital SNNP 229 AMBARE HEALTH CENTRE Health centre Somali 230 KEBRE BEYA HEALTH CENTRE Health centre Somali 231 KARA MARA HEALTH POST Health post Somali 232 JIJIGA KARAMARA HOSPITAL Referral/Specialized hospital Somali 233 MILLENIUM HOSPITAL Regional hospital Somali 235 KOREM HEALTH CENTRE Health centre Tigray 236 SAMARE HEALTH CENTRE Health centre Tigray 237 ADWA HEALTH CENTRE Health centre Tigray 238 AXUM HEATH CENTRE Health centre Tigray 239 MULU HEALTH CENTRE Health centre Tigray 59 | P a g e No. SDP Name Type of Facility Region 240 ADIGRAT HEALTH CENTRE Health centre Tigray 241 FEREWOYIN HEALTH CENTRE Health centre Tigray 242 BIR SHEWS HEALTH CENTRE Health centre Tigray 243 MENKERE HEALTH POST Health post Tigray 244 MYDELE HEALTH POST Health post Tigray 245 ADI MESANU HEALTH POST Health post Tigray 246 DEBANO HEALTH POST Health post Tigray 247 MAYE MESANU HEALTH POST Health post Tigray 248 ADWA HOSPITAL Regional hospital Tigray 249 ALAMATA DISTRICT HOSPITAL Rural hospital Tigray 250 WUKRO HOSPITAL Rural hospital Tigray 251 QUIHA HOSPITAL Rural hospital Tigray 252 MEAREG HOSPITAL Rural hospital Tigray 253 MEKELE HOSPITAL Zonal hospital Tigray 254 LEMLEM KARL HOSPITAL Zonal hospital Tigray 255 ADIGRAT ZONAL HOSPITAL Zonal hospital Tigray 60 | P a g e Annex C: Percentage distribution of service delivery points with modern contraceptive methods in stock at the time of the survey, October 2010 Disaggregation Percentage of modern contraceptive method in stock at the time of the survey M a le co n d o m O ra l p il ls IU C D Im p la n t In je ct a b le F e m a le co n d o m M a le st e ri li za ti o n F e m a le st e ri li za ti o n T o ta l (n ) Type of Facility Primary (Health post and health centre) 93.5 97.6 42.0 72.2 95.9 4.7 3.0 3.0 169 Secondary (rural, zonal, regional hospitals) 96.7 96.7 75.4 82.0 95.1 4.9 41.0 54.1 63 Tertiary (Referral/Specialized hospitals) 91.3 95.7 100.0 82.6 100.0 8.7 60.9 73.9 23 Region Tigray 100.0 100.0 47.6 65.2 100.0 0.0 9.5 19.0 21 Afar 100.0 100.0 60.0 60.0 80.0 0.0 20.0 20.0 5 Amhara 100.0 98.0 49.0 74.5 100.0 7.8 13.7 15.7 51 Oromia 93.7 100.0 57.0 72.2 93.7 7.6 19.0 21.5 80 Somali 80.0 100.0 40.0 60.0 100.0 20.0 0.0 0.0 5 Benshangul Gumuz 100.0 83.3 33.3 83.3 100.0 0.0 33.3 33.3 6 SNNP 93.6 91.5 40.4 72.3 100.0 4.3 14.9 21.3 48 Gambella 100.0 100.0 33.3 33.3 66.7 0.0 33.3 33.3 3 Harari 100.0 100.0 100.0 80.0 100.0 0.0 40.0 40.0 5 Addis Ababa 82.1 96.4 92.9 82.1 89.3 0.0 25.0 35.7 28 Dire Dawa 66.7 100.0 66.7 100.0 100.0 0.0 0.0 0.0 3 Residence Urban 95.5 97.8 72.1 86.0 95.5 5.6 23.5 29.6 179 Rural 90.5 95.9 14.9 50.0 97.3 4.1 2.7 2.7 76 Management Government 94.6 97.5 54.6 76.3 97.1 5.4 16.3 20.0 240 NGO 77.8 88.9 66.7 44.4 77.8 0.0 22.2 44.4 9 Private 100.0 100.0 75.0 100.0 75.0 0.0 75.0 75.0 6 Distance from nearest warehouse/ source of supplies (in Km)) 0-4 95.1 92.7 63.4 85.4 92.7 2.4 12.2 17.1 41 5-9 85.7 96.4 39.3 60.7 100.0 7.1 17.9 21.4 28 10-14 77.3 100.0 54.5 68.2 100.0 0.0 22.7 27.3 22 15-19 86.7 93.3 26.7 53.3 93.3 0.0 6.7 6.7 15 20-24 100.0 100.0 54.5 63.6 90.9 0.0 0.0 9.1 11 25-29 100.0 100.0 33.3 33.3 100.0 0.0 0.0 0.0 3 30-34 100.0 100.0 60.0 80.0 100.0 10.0 0.0 10.0 10 35-39 100.0 100.0 50.0 66.7 83.3 0.0 16.7 16.7 6 40-45 100.0 100.0 0.0 0.0 100.0 0.0 0.0 0.0 1 45-49 100.0 100.0 40.0 80.0 80.0 0.0 20.0 20.0 5 50 and over 98.2 98.2 62.2 82.9 97.3 8.1 23.4 27.9 113 Total 94.1 97.2 55.6 75.4 96.4 5.2 17.5 21.8 255 61 | P a g e Annex D: Percentage distribution of service delivery points with no stock out of any modern contraceptive method in the last six months, October, 2010 Disaggregation No stock out of any modern contraceptive method in the last six months M a le C o n d o m s F e m a le C o n d o m s O ra l P il ls In je ct a b le s IU D s Im p la n ts S te ri li za ti o n fo r F e m a le s S te ri li za ti o n fo r M a le s Type of Facility Primary (Health post and health centre) 84.6 5.4 94.1 89.3 46.2 74.0 7.8 6.0 Secondary (rural, zonal, regional hospitals) 95.1 8.2 91.8 85.2 73.8 75.4 50.8 41.0 Tertiary (Referral/Specialized hospitals) 91.3 13.0 100 89.3 95.7 82.6 73.9 60.9 Region Tigray 85.7 4.8 100 85.7 38.1 85.7 19.0 9.5 Afar 80.0 0.0 100 20.0 60.0 60.0 40.0 20.0 Amhara 92.2 7.8 92.2 96.1 47.1 74.5 13.7 11.8 Oromia 89.9 7.6 94.9 88.6 58.2 73.4 26.9 22.8 Somali 80.0 40.0 100 100 40.0 60.0 20.0 20.0 Benshangul Gumuz 100 0.0 83.3 100 50.0 83.3 33.3 33.3 SNNP 89.4 8.7 89.4 91.5 53.2 74.5 23.9 19.6 Gambella 100 0.0 100 66.7 33.3 33.3 33.3 33.3 Harari 100 0.0 100 100 100 80.0 40.0 40.0 Addis Ababa 71.4 0.0 96.4 85.7 92.9 78.6 35.7 25.0 Dire Dawa 66.7 0.0 100 100 66.7 100 0.0 0.0 Residence Urban 88.8 7.8 94.4 88.8 72.6 83.8 31.5 24.6 Rural 85.1 4.1 93.2 90.5 20.3 54.1 6.8 6.8 Management Government 88.3 7.1 94.2 90.0 56.7 75.8 22.3 18.0 NGO 0.0 0.0 100 75.0 75.0 100 100 100 Others 37.3 0.0 88.9 77.8 66.7 44.4 44.4 22.2 Distance from nearest warehouse/source of supplies (in Km)) 0-4 90.2 4.9 90.2 87.8 63.4 82.9 19.5 12.2 5-9 82.1 0.0 96.4 96.4 42.9 57.1 25.9 18.5 10-14 68.2 0.0 95.5 100 54.5 72.7 27.3 22.7 15-19 80.0 0.0 93.3 80.0 26.7 53.3 6.7 6.7 20-24 90.9 0.0 72.7 81.8 72.7 81.8 9.1 9.1 25-29 100 0.0 100 100 33.3 33.3 33.3 33.3 30-34 90.0 10.0 100 90.0 60.0 90.0 10.0 0.0 35-39 100 0.0 83.3 83.3 50.0 66.7 33.3 33.3 40-45 100 0.0 100 100 0.0 0.0 0.0 0.0 45-49 80.0 0.0 100 80.0 40.0 80.0 20.0 20.0 50 and over 91.9 12.6 96.4 88.3 64.0 80.2 30.0 25.2 Total 87.7 6.7 94.1 89.3 57.3 75.1 24.3 19.4

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