1. Effective Referral System for the Utilization of Critical Maternal and Newborn Health at Rural Health Centers of Ethiopia APHA 143 rd Annual Conference Chicago, Illinois

2. Low utilization of services and limited health system capacity Ethiopia has one of the highest maternal and neonatal mortality in the world Access and utilization of proven interventions to reduce both maternal and newborn deaths is low Multiple factors contribute to low utilization –Socio-cultural factors –limited number of skilled staff, well equipped and well functioning facilities –low quality of care –weak referral system Background

3. The Government of Ethiopia is increasing access to health care through: Health Extension Flagship Program Organizing primary health care units (PHCU) structure and strengthening the referral and support network Accelerated expansion of health centers Expanding access to BEmONC services at health centers Provision of ambulances to woredas to mitigate transportation barriers Government commitment and action Background

4. Background JSI/L10K’s Presence in Ethiopia Implements community-based RMNCH strategies –CBDDM and family conversation –Participatory community quality improvement (PCQI) –Family planning –Effective referral solutions To demonstrate innovative approaches to strengthening referral systems and refining those approaches for adoption and scaling across the country –iCCM/CBNC

5. The Referral Linkage Health center Communities Referral Hospital Referral Referring unit Transport Receiving unit

6. Innovation: The 3-step model for improving referral Assets: eg. Public transport Main barriers Low health care seeking behavior Absence of referral protocols & job aids Low quality of services Mapping of referral resources -Desk review -In-depth interviews -FGD Introduce referral protocols & job aids Build capacity of referral sites Improve care-seeking Performance review and supervision Participatory Design of innovations -Consultative workshop -Joint action plan HFs assigned liaison officer to coordinate referrals Communication and transport arrangement Active collaboration among referral levels Active management of referrals

7. Methods Registers and tools introduced to record the performance of the referral system Before and after cross-sectional facility surveys (health center and referral hospitals) was used to measure the effectiveness of the intervention –Baseline: March 2013 –Follow-up: December 2014 Data –Service statistics, six months retrospective –Interview –Records review

8. Methods.. Data from referral hospitals were limited to cases referred from the intervention health centers. Facility registers were reviewed to capture the required data and patient records were used to retrieve missing data. Descriptive and t-statistics were done to assess statistically significant differences in the outcome measures using Stata version 12.1.

9. Functioning referral system Adherence to specific referral protocols among maternal referrals out from the health center to hospital

10. Mean percentage score of maturity index Functioning Functioning referral system… Functioning

11. Functioning referral system P-value < 0.05

12. Increased utilization of emergency care Skilled delivery Met need for EmONC

13. Challenges Two-way communication though improving was a challenge Lack of ambulance back home service Efficient use of ambulance for obstetric and newborn emergencies;

14. Lessons learned  Engaging stakeholders across each level of the referral system created an awareness of the challenges and a greater sense of commitment to jointly address them  Consultative and monthly and quarter review meetings created a platform for building relationships across each level of the referral system  Utilization of lifesaving obstetric interventions has improved following the implementation of the effective referral solutions.

15. Thank you!! Thank you!!

16. Maturity index Maturity index It is implementation of core mechanisms to strengthen the management of the referral system including –Assignment of referral focal person/liaison officer at health center and hospital –Communication system to allow for calling ahead prior to referral –Dissemination of ambulance call numbers to communities –Development of standard protocols for who to refer, when and where –Distribution and training in the use of standard protocols –Referral-in and referral-out registers existing and being used –Referral slips (standardized and in place at health posts and health centers) –Regular meetings to address referral-related issues in each PHCU network