Agenda setting and socially contentious policies: Ethiopia's 2005 reform of its law on abortion

Background

In 2005, Ethiopia took a bold step in reforming its abortion law as part of the overhaul of its Penal Code. Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have liberalized their laws to permit safer, legal abortion.

Methods

This retrospective case study describes the actors and processes involved in Ethiopia’s reform and assesses the applicability of theories of agenda setting focused on internal versus external explanations. It draws on 54 interviews conducted in 2007 and 2012 with informants from civil society organizations, health professionals, government, international nongovernmental organizations and donors, and others familiar with the reproductive health policy context in Ethiopia as well as on government data, national policies, and media reports. The analytic methodology is within-case analysis through process tracing: using causal process observations (pieces of data that provide information about context, process, or mechanism and can contribute to causal inference) and careful description and sequencing of factors in order to describe a novel political phenomenon and evaluate potential explanatory hypotheses.

Results

The analysis of key actors and policy processes indicates that the ruling party and its receptiveness to reform, the energy of civil society actors, the “open windows” offered by the vehicle of the Penal Code reform, and the momentum of reforms to improve women’s status, all facilitated liberalization of law on abortion. Results suggest that agenda setting theories focusing on national actors—rather than external causes—better explain the Ethiopian case. In addition, the stronger role for government across areas of policy work (policy specification and politics, mobilization for enactment and for implementation), and the collaborative civil society and government policy relationships working toward implementation are largely internal, unlike those predicted by theories focusing on external forces behind policy adoption.

Conclusions

Ethiopia’s policymaking process can inform policy reform efforts related to abortion in other sub-Saharan Africa settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01255-z.

Globally, deaths of women due to unsafe abortion remain high. However, few countries have changed their laws to allow safer, legal abortion. In 2005, Ethiopia reformed its law to permit women to obtain an abortion for a significantly greater number of reasons, and this reform has resulted in a real expansion of women’s access to services.

This retrospective case study uses information from interviews with 54 people involved in Ethiopia’s reform and from government and research documents to see whether explanations of the reform that focus on the roles of national actors versus on the roles of external actors and influences better explain how Ethiopia’s reform took place.

This study finds that national actors and processes were most central to Ethiopia’s reform. In particular, a ruling party open to reform, the work of the women’s movement and of reproductive health nongovernmental organizations, the ability to take advantage of political events, and the collaborative relationship between government and nongovernmental organizations all supported reform. At the time, many major external actors were either against the reform (the U.S. government) or stayed neutral.

Findings can help those seeking to understand or plan policy reform efforts in other sub-Saharan Africa countries.

Patients’ perceptions of nurses’ communication in public hospitals of Harari Regional State, Eastern Ethiopia

Introduction:

The quality of nursing care has been evaluated using patient perception. Patients’ participation in nursing care and decision-making is regarded as a prerequisite for effective clinical practice; however, poor communication can lead to incorrect diagnosis and delayed, or ineffective medical treatment.

Objectives:

This study sought to assess admitted adult patients’ perceptions of, and factors influencing, nurse communication at public hospitals in Harar, eastern Ethiopia.

Methods:

Facility-based cross-sectional study was conducted among 377 admitted adult patients in Harar Town public Hospitals from 15 April to 30 May 2020. A proportionate stratified sampling technique was used to select the study participants. A pretested and structured questionnaire was used to collect data through a face-to-face interview and which were entered into EpiData and analyzed using SPSS. Bivariate and multivariate logistic regression analyses were conducted, odds ratio and confidence intervals were calculated and statistical significance was declared at p < 0.05.

Results:

This study outlined that the overall prevalence of good perception toward nurses’ communication was 41.9% (95% confidence interval = 37.1%, 46.9%). Patients whose age group were 26–35 years (adjusted odds ratio = 0.46 (95% confidence interval: 0.24, 0.86), Being female patients (adjusted odds ratio = 1.89; 95% confidence interval: 1.20, 2.98), admitted in private room (adjusted odds ratio = 3.25; 95% confidence interval: 1.91, 5.51), patients who have family support (adjusted odds ratio = 2.56; 95% confidence interval: 1.16, 3.64), urban residence (adjusted odds ratio = 0.65; 95% confidence interval: 0.02, 0.66) and language difference (adjusted odds ratio = 0.61; 95% confidence interval: 0.40, 0.94) were statistically significant.

Conclusion:

This study pointed out that less than half of the study participants had good perceptions toward nurses’ communication. As a result, increasing the number of health care providers who speak the same language as the patients and communication and behavioral change training must be prioritized.

Current and Future Needs for Human Resources for Ethiopia's National Health Information System: Survey and Forecasting Study

BACKGROUND

Strengthening the national health information system is one of Ethiopia's priority transformation agendas. A well-trained and competent workforce is the essential ingredient to a strong health information system. However, this workforce has neither been quantified nor characterized well, and there is no roadmap of required human resources to enhance the national health information system.

OBJECTIVE

We aimed to determine the current state of the health information system workforce and to forecast the human resources needed for the health information system by 2030.

METHODS

We conducted a survey to estimate the current number of individuals employed in the health information system unit and the turnover rate. Document review and key-informant interviews were used to collect current human resources and available health information system position data from 110 institutions, including the Ministry of Health, federal agencies, regional health bureaus, zonal health departments, district health offices, and health facilities. The Delphi technique was used to forecast human resources required for the health information system in the next ten years: 3 rounds of workshops with experts from the Ministry of Health, universities, agencies, and regional health bureaus were held. In the first expert meeting, we set criteria, which was followed by expert suggestions and feedback.

RESULTS

As of April 2020, there were 10,344 health information system professionals working in the governmental health system. Nearly 95% (20/21) of district health offices and 86.7% (26/30) of health centers reported that the current number of health information system positions was inadequate. In the period from June 2015 to June 2019, health information technicians had high turnover (48/244, 19.7%) at all levels of the health system. In the next ten years, we estimate that 50,656 health information system professionals will be needed to effectively implement the Ethiopia's national health information system.

CONCLUSIONS

Current health information system-related staffing levels were found to be inadequate. To meet the estimated need of 50,656 multidisciplinary health information system professionals by 2030, the Ministry of Health and regional health bureaus, in collaboration with partners and academic institutions, need to work on retaining existing and training additional health information system professionals.

Primary health care contributions to universal health coverage, Ethiopia

Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population’s health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.

Magnitude of Intention to Leave and Associated Factors among Health Workers Working at Primary Hospitals of North Gondar Zone, Northwest Ethiopia: Mixed Methods

Background

Human resource is the most crucial resources for the survival of an organization. Intention to leave is an employee's plan to leave their current job in the near future and is used as a proxy indicator for measuring turnover in cross-sectional surveys. In developing countries human resource shortages are not only due to production of health professionals but also because of employee turnover and instability at health facilities.

Objective

This study aimed to assess the magnitude of intention to leave and associated factors among health workers working at primary hospitals of North Gondar Zone, Northwest Ethiopia.

Methods

Institution based cross-sectional mixed methods' (both quantitative and qualitative) study design was conducted among health workers working at primary hospitals of North Gondar zone. Self-administered standardized structured questionnaires for quantitative and interview guide for qualitative were used for data collection. Variables having p-value less than 0.2 during bivariable analysis were entered into multivariable logistic regression model. Thematic analysis was done for qualitative data analysis.

Results

A total of 382 health workers were participated in the study with a response rate of 93.6%. Overall, 67.8% of them were intended to leave their current organization. Age of participants, 20-29 years (AOR=3.96; 95%CI: 1.04, 15.07), living out of family (AOR= 1.73; 95% CI: 1.23, 3.02), opportunity of other job (AOR= 2.04; 95% CI: 1.21, 3.45), performance appraisal system (AOR= 2.97; 95%CI: 1.64, 5.36), and affective commitment (AOR= 3.12; 95% CI: 1.64, 5.92) were the factors affecting health workers intention to leave current organization.

Conclusion

overall, magnitude of health workers intention to leave their current organization was high. Therefore, healthcare managers, supervisors, and policymakers need to develop and implement retention strategies that aim to improve the retaining of healthcare workers at their working organization such as unifying healthcare providers who are living separately with their families, use evidence-based performance evaluation mechanism, and make efforts to develop a sense of ownership in the health workers, which will reduce health professional's intention to leave their organization.

Impacts of working environment and benefits packages on the health professionals' job satisfaction in selected public health facilities in eastern Ethiopia: using principal component analysis

BACKGROUND

World Health Organization (WHO) predicted that there will be a shortfall of skilled healthcare by 2035 with the greatest shortfall in Africa and Southeast Asia due to satisfaction with payment and incentives. Low job satisfaction of health workers can result in increased staff turnover and absenteeism, which affects the efficiency of health services. Ethiopia has been affected by a shortage of health professionals due to a brain drain of health professionals. Our study, therefore, aimed at assessing the impact of the working environment and benefits packages on the level of satisfaction among health professionals working in selected public Health facilities in Eastern Ethiopia.

METHODS

Institutional based Cross-sectional study design was conducted among 422 selected health professionals in Bale Zone Public Health Facilities. After selecting 2 hospitals and 32 health centers by lottery method, proportional allocation of the sample was done for selected Hospitals and Health Centers. Then, to select individual health professional from each health center and hospital, a systematic sampling method was employed using the worker's registration log book. Then, data were collected, cleaned and entered into EpiData software version 3.1 and then exported to IBM SPSS version 21 for analysis. Both descriptive and inferential statistics were done. The principal component analysis was employed for all Likert scale instruments to extract factor(s) representing each of the scales and have factor scores, which facilitate treatment of the variables as continuous during further analysis. Using this regression factor score, multiple linear regression analysis was performed and the effect of independent variables on the regression factor score of the outcome variable was quantified. A significance level of less than 0.05 was used in all cases to judge statistical significance.

RESULT

This study showed that the prevalence of job satisfaction of health professionals was 38.5% (95%CI: 33.82-43.2%). Age of health professionals ((β = 0.252, (95% CI: 0.067, 0.437))), type of health facility (β = - 0.280, (95% CI; - 0.519, - 0.041), service year (β = 0.487, (95%CI: 0.025, 0.998)), supply they need to do their job (β = 0.10, (95% CI: 0.009 to 0.19)), perception of health professional on allowances (β = - 0.216, (95% CI: - 0.306, - 0.125)) and perception of health professionals on employment benefits (β = 0.225, (95% CI: 0.135 to 0.315)) were statistically significant that affect job satisfaction factor score.

CONCLUSION

level of job satisfaction of health professionals was found to be low. Level of job satisfaction was influenced by the age of the health professionals, type of health facility in which they were working, years of service they had in the health sectors, their working environment, professional allowance and benefits like financial rewards and benefits of being employed. Hence, policy makers and health managers need to pay special attention to increase the satisfaction of the health workforce at all levels in the health system. Moreover, special emphasis should be given for the benefits packages of health workers at different levels.

Women health extension workers: Capacities, opportunities and challenges to use eHealth to strengthen equitable health systems in Southern Ethiopia

OBJECTIVES

This study assesses the feasibility of female health extension workers (HEWs) using eHealth within their core duties, supporting both the design and capacity building for an eHealth system project focussed initially on tuberculosis, maternal child health, and gender equity.

PARTICIPANTS

Health extension workers, Health Centre Heads, District Health Officers, Zonal Health Department and Regional Health Bureau representatives in Southern Ethiopia.

SETTING

The study was undertaken in Southern Ethiopia with three districts in Sidama zone (population of 3.5 million) and one district in Gedeo zone (control zone with similar health service coverage and population density).

METHODS

Mixed method baseline data collection was undertaken, using quantitative questionnaires (n = 57) and purposively sampled qualitative face-to-face semi-structured interviews (n = 10) and focus group discussions (n = 3).

RESULTS

Themes were identified relating to HEW commitment and role, supervision, and performance management. The Health Management Information System (HMIS) was seen as important by all participants, but with challenges of information quality, accuracy, reliability and timeliness. Participants' perceptions varied by group regarding the purpose and benefits of HMIS as well as the potential of an eHealth system. Mobile phones were used regularly by all participants.

CONCLUSION

eHealth technology presents a new opportunity for the Ethiopian health system to improve data quality and community health. Front-line female HEWs are a critical bridge between communities and health systems. Empowering HEWs, supporting them and responding to the challenges they face will be an important part of ensuring the sustainability and responsiveness of eHealth strategies. Findings have informed the subsequent eHealth technology design and implementation, capacity strengthening approach, supervision, and performance management approach.

Client satisfaction determinants in four Kenyan slums

PURPOSE

In Kenya, gaps exist in health service provision to slum residents, especially service availability and access to quality care. There is also little information on the health status of people living in slums other than in Nairobi. The purpose of this paper is to generate evidence for use in designing interventions to improve health services in four mid-sized slums in Embu, Nyeri and Thika, Kenya.

DESIGN/METHODOLOGY/APPROACH

A cross-sectional survey of clients receiving services in health facilities was conducted in the targeted slums. Data were collected through face-to-face interviews. Factor scores were generated using the Rasch model; simple and multivariate logistic regression analyses were done using the R statistical software.

FINDINGS

Overall, 81 per cent of the 203 participants reported being satisfied with health services. Most clients (89 per cent) reported that health facility staff greeted them warmly; 82 per cent said their consultation was private. The facility type, waiting time and client experience with service providers determined their satisfaction (p<0.05).

PRACTICAL IMPLICATIONS

Healthcare managers can improve client satisfaction levels by understanding the client flow in their facilities and addressing causes of client dissatisfaction, such as long waiting times, while at the same time promoting facilitating factors.

ORIGINALITY/VALUE

The authors use latent variable modelling to compute client satisfaction scores, which were dichotomised into two categories and fitted into a logistic regression model to identify factors that influence client satisfaction. Health facility clients in the four slums are satisfied with services and have confidence the providers will serve them in a friendly and professional manner that promotes respect and quality care. The paper recommend healthcare managers in similar settings carry out client flow analysis and institute remedial measures to address long waiting times. Qualitative studies are recommended to determine the reasons behind the high satisfaction levels reported in this study.

Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices

Corrado Cancedda and colleagues outline a framework for health professional training initiatives in low-income countries.

Determinants of satisfaction with health care provider interactions at health centres in central Ethiopia: a cross sectional study

BACKGROUND

In primary health care, provider-patient interaction is fundamental platform and critically affects service delivery. Nevertheless, it is often ignored in medical research and practice and it is infrequently subjected to scientific inquiry, particularly in Ethiopia. This study aimed to assess patient satisfaction with health care provider interactions and its influencing factors among out-patients at health centers in West Shoa, Central Ethiopia.

METHODS

A cross sectional facility based study was conducted on 768 out-patients of six health centers in West Shoa Zone, Central Ethiopia. The total sample size was allocated to each of the six health centers based on patient flow during the ten days prior to the start of data collection. Pre-tested instruments were used for data collection and the data were analyzed using SPSS version 16.0 statistical software. Factor score was computed for the items identified to represent the satisfaction scale by varimax rotation method. Using this regression factor score, multivariate linear regression analysis was performed and the effect of independent variables on the regression factor score was quantified.

RESULTS

Seventy three percent of the respondents perceived that provider's empathy was good and 35% complained that providers were not technically competent enough. In addition, 82% of the respondents rated non-verbal communication by the providers to be good, very good or excellent on a five-point ordinal scale. Regardless of the process, only 34.1% of the patients implied that the consultations made a difference in understanding their illness and coping with it. Generally speaking, 62.6% of the patients reported that they have been satisfied with their visit. Perceived empathy, perceived technical competency, non-verbal communication, patient enablement, being told the name of once illness, type and frequency of visit, knowing the providers and educational status were main independent predictors of patient satisfaction in this study. Furthermore, very good empathy (Beta = -4.323), fair non-verbal communication (Beta = -0.188), fewer expectations met (Beta = -0.169) and disagreement to technical competency (Beta = -0.156) had greater negative influence on patient satisfaction. On the other hand, excellent non-verbal communication (Beta = 0.114) and being told the name of once illness (0.109) had pronounced positive influence on patient satisfaction.

CONCLUSION

The present study showed that interpersonal processes including perceived empathy, perceived technical competency, non-verbal communication and patient enablement significantly influence patient satisfaction. Therefore, health care providers should work towards improving the communication skill of their professionals along with having technically competent workers which could possibly affect the perception of the patient about all of the variables identified as independent predictors of patient satisfaction in this study.