BACKGROUND:Prenatal multiple micronutrient supplementation (MMS) including iron, folic acid, and other essential micronutrients, has shown potential to improve birth outcomes in controlled studies. We did an effectiveness study in Ethiopia to determine the effect on mean birthweight of MMS provided as part of routine antenatal care, relative to iron-folic acid supplementation (IFA). METHODS:A pragmatic, two-arm, facility-based, cluster-randomised controlled trial was conducted across 42 districts in five regions of Ethiopia to determine the effect on birthweight of MMS relative to IFA. Districts were randomly assigned to either retain IFA as part of routine antenatal care or switch to MMS. Randomisation was stratified by region and done using a random number generator within statistical software. All live singleton births at participating health facilities were eligible for inclusion and birthweights were recorded. Additionally, data were collected on maternal receipt and utilisation of MMS or IFA. The primary outcome was birthweight, analysed in the intention-to-treat population. This completed trial is registered at ClinicalTrials.gov, NCT05708183. FINDINGS:Between Jan 1, 2023, and Dec 31, 2024, birthweights were recorded for 47 325 babies in the 21 IFA districts and 36 473 babies in the 21 MMS districts. Mean age of mothers was 26·2 years (SD 5·3) and median gestational age of babies at birth was 38 weeks (IQR 38-39). The effect of MMS on birthweight was a mean increase of 38 g (95% CI 20-55) in the MMS arm relative to the IFA arm after adjustment for time, geographical region stratification factor, gestational age, sex of baby, and parity. Among women who reported taking at least 90 tablets of their assigned supplement, the increase in mean birthweight in the MMS arm relative to the IFA arm was 58 g (38-79). Stillbirth risk was 7·5 per 1000 births in the IFA arm and 6·9 per 1000 births in the MMS arm. INTERPRETATION:The findings of this trial are consistent with those from efficacy trials in other settings, indicating that the transition from IFA to MMS as part of routine antenatal care in Ethiopia could lead to a small but clear improvement in birthweight, although adherence to supplements and programme sustainability require careful attention. FUNDING:Children's Investment Fund Foundation.

Objective Our objective was to assess the feasibility of using the routine health information system data source, District Health Information System (DHIS2) to measure the effective coverage of selected health service indicators in Ethiopia and to explore stakeholder perceptions of those measures.Design We conducted a mixed-methods study. We mapped the availability of data elements in DHIS2 between July 2022 and June 2023 for five indicators (four or more antenatal care visits (ANC4+), skilled birth attendance, postnatal care, sick child care and child nutrition care). We defined effective coverage cascade steps for each indicator, assessed data quality and analysed data using STATA V.17. Finally, qualitative interviews were conducted with 15 key stakeholders, and the data were analysed thematically for reflections on the DHIS2 output.Setting The data were captured from all public health facilities of 11 regions and 2 administrative cities in Ethiopia.Results There was better availability of data elements for maternal healthcare than for child healthcare. It was possible to estimate the intervention-adjusted coverage of ANC4+ (16% nationally) and the process-quality-adjusted coverage of skilled birth attendance (19% nationally). Postnatal care, sick child care and child nutrition indicators lacked data across multiple cascade steps. The quality of data for effective coverage measurement differed by region. The key informants expressed concerns about the adequacy and appropriateness of DHIS2 data for this analysis. While all acknowledged its potential for decision-making, respondents emphasised the need for standardised methods and data sources to enhance comparability and acceptability of the findings.Conclusions The findings underscore the need for system-level improvement of data availability and quality, and adoption of a standardised approach to calculating effective coverage using DHIS2. There was a concern that the findings may not be accepted by policymakers; however, the local level granularity made possible through DHIS2 was appreciated.

Effective coverage measurement has emerged as a tool to help understand health system performance for the provision of high-quality health care. Using a cascade approach that combines data on demand- and supply-side steps, effective coverage measures highlight where gaps in the health system exist and how improvements might be made so that more people benefit from the potential of the health services available to them. In practice, however, there are challenges in making this work. This analysis paper aimed to highlight those challenges in calculating effective coverage in Ethiopia, using antenatal care as a test case, and propose a solution.In Ethiopia, government leaders are committed to taking a data-informed approach to improving health care quality. To support this, an effective coverage technical working group was formed of individuals with experience of effective coverage analysis in Ethiopia to share knowledge and create learning for a way forward.Through methods analysis of one common indicator, the effective coverage of antenatal care, four key challenges were identified by the group: (1) features of the data sources used, (2) the number of cascade steps included in the effective coverage calculations, (3) the data elements included within cascade steps and (4) the methods applied to generate composite indicators.Multiple small differences were observed to have an influence on the usability of effective coverage measures for decision-making. The group concluded that greater transparency in reporting effective coverage measures was urgently needed and proposed and discussed the use of a reporting checklist for this purpose.

Introduction This programme effectiveness study responds to the need for evidence of the effect on birth weight of switching from iron-folic acid supplementation to multiple micronutrient supplementation as part of routine antenatal care in Ethiopia. A 2019 meta-analysis reported a mean increase of 35 g in birth weight among newborns of women who took multiple micronutrient supplements in pregnancy compared with those who took iron-folic acid. Responding to that evidence, the government of Ethiopia decided to implement a 21 district pilot of the use of multiple micronutrient supplementation in routine antenatal care and requested an evaluation of implementation outcomes, including on birth weight.Methods and analysis A pragmatic, facility-based, randomised trial is being conducted in 42 districts over five regions of Ethiopia between January 2023 and December 2024. Districts have been randomised to one of the two arms, either to retain iron-folic acid supplementation as part of routine antenatal care or switch to multiple micronutrient supplementation. During the study period, the birth weights of all eligible babies born in enrolled health facilities in these 42 districts are continuously recorded alongside data on maternal receipt and use of either multiple micronutrient or iron-folic acid supplementation. We hypothesise that newborns of women resident in the 21 multiple micronutrient supplementation districts will have higher mean birth weight than newborns of women resident in the 21 iron-folic acid supplementation districts. Facility surveys involving pregnant women and healthcare workers at baseline, midline and endline contribute to a process evaluation and cost and cost-effectiveness evaluation.Ethics and dissemination The study received ethical approval from the review boards at the Ethiopian Public Health Institute (EPHI-IRB-455-2022) and the London School of Hygiene & Tropical Medicine (LSHTM ref 28021). Results from this pragmatic trial will be used by the government of Ethiopia in assessing success of the multiple-micronutrient supplements pilot and for decision making about subsequent scale-up. Dissemination of findings will also inform global decision making, particularly in settings where a transition from iron-folic acid to multiple micronutrient supplementation is being contemplated at scale.Trial registration number NCT05708183.

Ethiopia implemented the community-based management of possible serious bacterial infection to improve access to lifesaving care for sick young infants aged 0–2 months. However, service utilization has been low, and the quality of care was sub-optimal, emphasizing the need to identify challenges within the primary healthcare system. This study explored mothers’ and healthcare providers’ experiences and perspectives on the management of sick young infants, including those with possible serious bacterial infections to inform policy and practice. We conducted a qualitative study including 25 in-depth and six key informant interviews with purposively selected participants, including mothers seeking facility care for their infants, health extension workers, health center staff, and supervisors of health extension workers. We audio-recorded and transcribed the interviews, and conducted inductive thematic analysis. We present four major themes: caregivers’ perceptions of young infant illnesses, caregivers’ choice of place to seek care, caregivers’ experiences with caring for sick young infants at the health facility, and factors affecting the provision of quality care. Mothers acknowledged the need to seek care if their young infants became ill, although often delayed when not recognizing signs of illness, believing that it would resolve. Once identified, they had the autonomy to seek care but lacked awareness of health post services, bypassing these and seeking care at health centers, which were further away. Health extension workers viewed poor infrastructure and the perceived low quality of service as being linked to low service utilization at health posts. Mothers described long waiting times at health centers, inadequate assessment, and missing communication about their children’s conditions and treatment. Health extension workers felt they had gaps in knowledge and skills. Inconsistent availability of drugs, weak referral and feedback mechanisms, low-quality supervision, limited mentorship, and inadequate district-level ownership of newborn care constrained the delivery of high-quality services. This study identifies the challenges from the community to health system on sick young infants’ service utilization and quality of care at primary healthcare settings. It highlights the importance of a comprehensive approach that integrates demand-creation activities with health system strengthening efforts to ensure the consistent availability of high-quality care.

Global consensus has shifted to focus on how children can be supported to not only 'survive' but to 'thrive'. Blindness and visual loss in early childhood undermine a child's ability to thrive, affecting psychomotor, cognitive, and social development leading to life-long consequences for educational attainment, employment, economic and social status, and wellbeing. Despite this, eye health for children under the age of 5 years has been neglected, and not politically prioritized. In Tanzania, policy makers decided in 2019 to include eye conditions in the national Integrated Management of Newborn and Childhood Illness (IMNCI) programme, despite eye health not being part of the global World Health Organization/UNICEF IMNCI strategy. We conducted a qualitative policy analysis to explore enabling factors and barriers to this policy change. The interviews were semi-structured with key actors selected purposively and by snowball sampling, including those with a role in child and eye health at national and global levels. We used an adapted Shiffman and Smith framework (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007;370:1370-9) to guide the interviews and analysis, and the Consolidated Criteria for Reporting Qualitative Research for planning and reporting. This study shows how rapidly one country altered its overall child health policy to include eye health, driven by good quality collaborative research and collective action (cohesive policy community) which importantly included co-design with the decision makers (Ministry of Health actors). These developments coincided with the shift in the international agenda moving from 'survive to thrive' in child health which was leveraged to include eye care in the national strategy.

BACKGROUND:The World Health Organization has listed several newborn care practices as essential for health and survival. Reports from low-income countries, including Ethiopia, have shown inequities in these practices, but their link to place of birth remains insufficiently explored. We aimed to analyze the wealth-based equity of selected essential newborn care practices, i.e., skin-to-skin care, delayed bathing, proper cord care, and timely breastfeeding initiation, among neonates born in health facilities and homes in Ethiopia. METHODS:The Performance Monitoring for Action Ethiopia 2019-2020 survey was conducted in five regions, representing 90% of the country's population, and included data on 2,493 newborns. Household wealth quintiles were derived using principal component analysis of asset ownership. We analyzed the wealth-based equity of selected essential newborn care practices for facility and home deliveries using equiplot, equity gaps, equity ratios, and concentration indices. RESULTS:Overall, skin-to-skin care and delayed bathing showed minimal inequities among babies born in health facilities. When comparing the extreme wealth groups, minor socio-economic differences were observed in delayed bathing and timely breastfeeding initiation. When wealth was treated as a continuous variable across all respondents, delayed bathing and proper cord care were more common in better-off households. For home births, the equiplots showed that all selected essential newborn care practices were more frequent among the least poor groups. While comparing the extreme wealth groups, socio-economic inequities were evident in skin-to-skin care and delayed bathing practices. When wealth was considered a continuous variable, skin-to-skin care and delayed bathing were more common among better-off households. CONCLUSION:The coverage of selected essential newborn care practices was higher in facility deliveries. There were minimal socio-economic differences in newborn care for facility births, while inequities in skin-to-skin care and delayed bathing were prominent in home births. Initiatives should aim to enhance equity in newborn care within health facilities while promoting facility deliveries and improving newborn care practices at home to achieve equitable newborn care in Ethiopia.

WHO recommends essential newborn care practices that every newborn needs for health and survival regardless of birthplace. Previous Ethiopian studies of these actions had long recall periods and most considered either facility or home deliveries. We aimed to assess selected practices, i.e., thermal care, cord care, initiation of breastfeeding, and first immunizations among neonates born at health facilities and homes in Ethiopia. We used data from the Performance Monitoring for Action Ethiopia 2019–2020 survey and analyzed 2,493 live births whose mothers completed interviews at seven weeks postpartum in five regions, namely Tigray, Afar, Amhara, Oromia, Southern Nations, Nationalities and Peoples regions, and Addis Ababa. Practices were assessed using an interviewer-administered questionnaire. Essential newborn care indicators were analyzed among neonates born at health facilities and homes and expressed as proportions with a 95

BACKGROUND:Addressing disparities in reproductive, maternal, newborn, and child health services is crucial in achieving the Sustainable Development Goal of universal health coverage. The persistence of social and geographic disparities in maternal health service coverage and utilization poses significant challenges. Ensuring equity in health service access and utilization as part of universal health coverage requires evidence whether these inequities exist. This study aimed to measure socio-economic and geographic equity in coverage and effective coverage of both antenatal care and skilled birth attendance. METHODS:We conducted a secondary analysis of data collected from the Performance Monitoring for Action Ethiopia from 2019 to 2020, including 2714 postpartum women at around six weeks and service delivery point assessment data from 462 health facilities. We measured inequities in the utilization of four or more antenatal care visits and skilled birth attendance using equiplots and concentration index. Moran's I, Getis-Ord Gi statistics and Kriging interpolations were employed to analyze geographic variations of maternal health service utilization. RESULTS:In this study, 40% (95%CI: 36, 45) utilized four or more ANC visits, and 12% (95%CI: 11, 14) received quality antenatal care. Over half (54%, 95%CI: 48, 59) of women utilized skilled birth attendance, but only 7% (95%CI: 4, 8) received quality delivery care. The absolute equity gap between the least poor and the poorest women was 43 percentage points for ANC visits and 65 percentage points for skilled birth attendance. A higher proportion of women in Central and Northern parts of Ethiopia had four or more ANC visits and utilized skilled birth attendance, while most parts of the Eastern part of the country and most areas in the South had low levels of utilization. CONCLUSION:The coverage of four or more antenatal care visits and skilled birth attendance was low and inequitable, with the poorest women receiving fewer services. The coverage varied across different parts of the country. Interventions that target groups of women and geographic areas with low coverage of services are crucial for reaching the goal of universal health coverage.

BackgroundSkilled birth attendance is among the crucial maternal health interventions for maternal and neonatal mortality reduction. The availability of core components of services at healthcare facilities and the quality-of-service provision are essential for the effective utilization of skilled birth attendance. Effective coverage measures the availability of essential components at health facilities and the quality of care delivered. This study aimed to measure effective coverage of skilled birth attendance in Ethiopia.MethodsWe applied the cascade approach to measure effective coverage, focusing on four steps up to quality-adjusted coverage as a proxy for effective coverage of skilled birth attendance. To assess the structural quality of facilities, we used the PMA service delivery assessment data in 2019. Effective coverage was defined as the product of skilled birth attendance, facility readiness score, intervention coverage (proportion who received uterotonic injection), and a process quality score.ResultsThe crude coverage for skilled delivery attendance was 54% (95%CI; 52, 56). The average level of facility readiness to provide skilled delivery service was 72%, ranging from 17% for private and non-governmental facilities to 88% for hospitals. The uterotonic injection coverage was 42% and the mean process quality for skilled delivery service was 46%. Based on the effective coverage cascade, the input-adjusted coverage was 38%, and the intervention-adjusted coverage was 16%, and the quality-adjusted coverage was 7%.Low level of facility readiness and low quality of service explain the low effective coverage of skilled delivery attendance. Apart from the overall low level of readiness, there was variability between different levels of facilities. Though the skilled delivery attendance coverage is improving, the low level of readiness, intervention provision, and poor process quality resulted in low effective coverage. The minimum level of readiness needs to be ensured at all levels of facilities to provide skilled delivery services. The minimum level of service readiness and quality of care need to be ensured at all facilities to provide skilled birth attendance.ResultsThe crude coverage for skilled delivery attendance was 54% (95%CI; 52, 56). The average level of facility readiness to provide skilled delivery service was 72%, ranging from 17% for private and non-governmental facilities to 88% for hospitals. The uterotonic injection coverage was 42% and the mean process quality for skilled delivery service was 46%. Based on the effective coverage cascade, the input-adjusted coverage was 38%, and the intervention-adjusted coverage was 16%, and the quality-adjusted coverage was 7%.Low level of facility readiness and low quality of service explain the low effective coverage of skilled delivery attendance. Apart from the overall low level of readiness, there was variability between different levels of facilities. Though the skilled delivery attendance coverage is improving, the low level of readiness, intervention provision, and poor process quality resulted in low effective coverage. The minimum level of readiness needs to be ensured at all levels of facilities to provide skilled delivery services. The minimum level of service readiness and quality of care need to be ensured at all facilities to provide skilled birth attendance.

In low and middle-income countries, addressing maternal and child nutrition needs is crucial. Prenatal multiple micronutrient supplementation (MMS) holds promise in reducing low birthweight and preterm births. Ethiopia is considering a transition from the provision of iron-folate supplementation to the provision of MMS in antenatal care, guided by WHO guidelines. This paper explores stakeholders' early perceptions and experiences in piloting that transition in five Ethiopian regions, informing decision making about future policy and scale-up. We used a qualitative study involving interviews and document reviews to assess the MMS pilot, analyzing themes with Nvivo 12 software. Key informant interviews revealed challenges such as supply chain issues and funding constraints, along with proposed improvement strategies such as closer coordination within existing structures. The importance of engaging with communities to create demand was emphasized, as was the need for capacity-building efforts utilizing existing staff in the health system with a clear plan for ongoing refresher training. Finally, enhancing the monitoring and evaluation framework, including a dedicated regional team for supportive supervision, was vital for accountability. In conclusion, prioritizing supply chain strengthening, community engagement through demand creation, coordination, and continuous capacity building for healthcare workers were thought to be crucial for the MMS program's success. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05708183 Registered 01 February 2023-Retrospectively registered, https://classic.clinicaltrials.gov/ct2/show/NCT05708183.

Objectives To assess the geographical equity in Ethiopian infants’ exclusive breastfeeding at 5 months and dietary diversity at 12 months and whether social factors explained the spatial inequities.Design Secondary analysis of a birth cohort study.Setting Analysis of data from the Ethiopian Performance Monitoring for Action panel study conducted from July 2020 to August 2021 in five regions (ie, Oromia, Amhara, Afar and Southern Nations, Nationalities and Peoples regions and the Addis Ababa City administration). We analysed geographical autocorrelation to assess geographical variations in exclusive breastfeeding and dietary diversity. Areas with higher and lower coverage of appropriate infant feeding outcomes were analysed using hotspot analyses. We performed geographically weighted regression to investigate whether sociodemographic factors explained the geographical feeding differences.Participants 1850 infants were prospectively followed from birth to 12 months.Outcome measures Exclusive breastfeeding at 5 months and minimum-level dietary diversity at 12 months.Results Sixty-nine percent (95% CI 67 to 71) of infants were exclusively breastfed at 5 months, while at 12 months, only 16% (95% CI 13 to 19) had complementary feeding from five or more food groups. There were geographical variations in the coverage of exclusive breastfeeding and minimum dietary diversity. Higher proportions of infants were exclusively breastfed at 5 months in northern areas, and more 12-month-old infants in central parts of the country had complementary feeding from at least five food groups. Sociodemographic factors explained a quarter of the geographical variation in dietary diversity.Conclusion Most Ethiopian infants were exclusively breastfed, which was in line with global recommendations but with some geographical differences. There was prominent geographical variation in dietary diversity, partly explained by social factors, but overall, very few 12-month-old infants were fed from at least five food groups. This low dietary quality could impair Ethiopian children’s physical growth, development and health.

ABSTRACT Appropriate infant feeding is crucial to ensure optimal child growth and survival. We aimed to assess infants' breastfeeding and complementary feeding practices from 0 to 12 months in Ethiopia. This study was a secondary analysis of data from the Ethiopia Performance Monitoring for Action panel study performed from July 2020 to August 2021. One thousand eight hundred and fifty infants were included from five Ethiopian regions: Addis Ababa City Administration, Oromia, Amhara, Afar, and Southern Nations, Nationalities, and Peoples Regions. Appropriate infant feeding practices were assessed using the World Health Organization measurement criteria and descriptive analysis. One‐year‐old infants were considered to have a diversified diet if they had complementary feeding comprising five or more food groups. Two‐thirds (67%, 95% CI: 63, 71) of newborns were put to the breast within 1 h after delivery. The median duration of exclusive breastfeeding was 6.5 months, and 69% (95% CI: 67, 71) were exclusively breastfed at 5 months. Almost all (97%; 95% CI: 96, 98) were still breastfeeding at 12 months. Sixteen percent (95% CI: 13, 19) of infants (boys 15%, girls 16%) aged 12 months had a diversified diet, and 49% (95% CI: 44, 55) consumed sugary foods or beverages. Most Ethiopian infants had appropriate breastfeeding practices, while almost all had poor‐quality complementary food at 1 year. Increasing access to high‐quality education on infant feeding is crucial to maintaining and enhancing appropriate breastfeeding practices and complementary food quality. Intensifying poverty reduction efforts are essential to improve infants' dietary diversity and nutrient‐dense food consumption.

BACKGROUND:Essential newborn care is a set of measures every newborn baby needs, regardless of its birthplace. Geographic equity in essential newborn care refers to the fairness of access to newborn care across different regions. These practices vary across different social groups, but evidence on the geographic equity of newborn care in Ethiopia is scarce. We aimed to assess the geographic distribution and equity of selected essential newborn care practices (initial skin-to-skin care, delayed bathing, proper cord care, timely breastfeeding initiation, and immunizations of BCG and first-dose polio vaccines) recommended by the World Health Organization among neonates born at health facilities and homes in Ethiopia. METHODS:We analyzed cross-sectional survey data from 2,493 neonates in the Performance Monitoring for Action (PMA) Ethiopia 2019-2020 survey in five regions and the Addis Ababa City Administration. The survey employed a cross-sectional study design, and the data were collected from 2019 to 2020. We studied the geographic variation of selected essential newborn care practices using Global Moran's I statistics and hot and cold spot analysis (Local Getis-Ord Gi* statistic), and the coverage of these practices were predicted for the whole country using Kriging interpolation. RESULTS:This study showed that selected essential newborn care practices were higher among neonates in health facilities, those born in Central, Northern, Southern, and a few areas in Southwest and Northwest Ethiopia. Geographic inequities were demonstrated in delayed bathing in facility and home births, proper cord care in facility births, and first immunizations in both facility and home births. Geographic inequities were not observed for initial skin-to-skin care and timely breastfeeding initiation. CONCLUSION:Selected essential newborn care practices were higher among neonates born in health facilities, and the recommended essential newborn care practices were higher in Central and Northern Ethiopia. There were geographic inequities in delayed bathing and immunizations of BCG and first-dose polio vaccines among neonates born in health facilities and homes. Enhancing facility delivery, availing first vaccinations in facilities, and improving discharge counseling for mothers during antenatal, delivery, and postnatal care are crucial to ensuring geographic equity in essential newborn care in Ethiopia.

Monitoring social equity in infant feeding is essential to track countries’ progress towards global child nutrition and survival targets. We aimed to examine social equity in Ethiopian infants’ early initiation of breastfeeding, exclusive breastfeeding at five months, and quality of complementary foods at 12 months. This study was a secondary analysis of the Ethiopia Performance Monitoring for Action panel data, prospectively collected from July 2020 to August 2021. A total of 1,850 infants were followed from birth to 12 months in five Ethiopian regions: Addis Ababa City Administration, Oromia, Amhara, Afar, and Southern Nations, Nationalities, and Peoples Regions. We analyzed social equity in infants’ early initiation of breastfeeding, exclusive breastfeeding at five months of age, and dietary diversity at 12 months of age, calculated slope and concentration indices and using mixed-effect regression models. Most infants started breastfeeding within one hour of birth (67

Background Use of local data for health system planning and decision-making in maternal, newborn and child health services is limited in low-income and middle-income countries, despite decentralisation and advances in data gathering. An improved culture of data-sharing and collaborative planning is needed. The Data-Informed Platform for Health is a system-strengthening strategy which promotes structured decision-making by district health officials using local data. Here, we describe implementation including process evaluation at district level in Ethiopia, and evaluation through a cluster-randomised trial.Methods We supported district health teams in 4-month cycles of data-driven decision-making by: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritising; and (e) a consultative process to develop, commit to and follow up on action plans. 12 districts were randomly selected from 24 in the North Shewa zone of Ethiopia between October 2020 and June 2022. The remaining districts formed the trial’s comparison arm. Outcomes included health information system performance and governance of data-driven decision-making. Analysis was conducted using difference-in-differences.Results 58 4-month cycles were implemented, four or five in each district. Each focused on a health service delivery challenge at district level. Administrators’ practice of, and competence in, data-driven decision-making showed a net increase of 77% (95% CI: 40%, 114%) in the regularity of monthly reviews of service performance, and 48% (95% CI: 9%, 87%) in data-based feedback to health facilities. Statistically significant improvement was also found in administrators’ use of information to appraise services. Qualitative findings also suggested that district health staff reported enhanced data use and collaborative decision-making.Conclusions This study generated robust evidence that 20 months’ implementation of the Data-Informed Platform for Health strengthened health management through better data use and appraisal practices, systemised problem analysis to follow up on action points and improved stakeholder engagement.Trial registration number NCT05310682.

Abstract Background Antenatal care (ANC) is a principal component of safe motherhood and reproductive health strategies across the continuum of care. Although the coverage of antenatal care visits has increased in Ethiopia, there needs to be more evidence of effective coverage of antenatal care. The 'effective coverage' concept can pinpoint where action is required to improve high-quality coverage in Ethiopia. Effective coverage indicates a health system's performance by incorporating need, utilization, and quality into a single measurement. The concept includes the number of contacts, facility readiness, interventions received, and components of services received. This study aimed to measure effective antenatal care coverage in Ethiopia. Methods A two-stage cluster sampling method was used and included 2714 women aged 15–49 years and 462 health facilities from six Ethiopian regions from October 2019 to January 2020. The effective coverage cascade was analyzed among the targeted women by computing the proportion who received four or more antenatal care visits where the necessary inputs were available, received iron-folate supplementation and two doses of tetanus vaccination according to process quality components of antenatal care services. Results Of all women, 40% (95%CI; 38, 43) had four or more visits, ranging from 3% in Afar to 74% in Addis Ababa. The overall mean health facility readiness score of the facilities serving these women was 70%, the vaccination and iron-folate supplementation coverage was 26%, and the ANC process quality was 64%. As reported by women, the least score was given to the quality component of discussing birth preparedness and complication readiness with providers. In the effective coverage cascade, the input-adjusted, intervention-adjusted, and quality-adjusted antenatal coverage estimates were 28%, 18%, and 12%, respectively. Conclusion The overall effective ANC coverage was low, primarily due to a considerable drop in the proportion of women who completed four or more ANC visits. Improving quality of services is crucial to increase ANC up take and completion of the recommended visits along with interventions increasing women’s awareness.

Introduction Globally adolescents and young adults (AYA) with tuberculosis (TB) face unique challenges. Until recently they have received little attention and few tailored interventions exist. To improve TB outcomes in this population, there is a need to implement tailored interventions. However, limited research has been conducted about how to meet the needs of AYA with tuberculosis. In this paper we present the findings of a qualitative study to explore the needs of AYA with TB in Zimbabwe and to identify interventions to optimize their engagement in TB care. Methods We conducted two participatory workshops with 16 AYA, aged 10-24 years diagnosed with TB to explore their experiences of TB disease and treatment. Through subsequent interviews with 15 of the same AYA and with two other key stakeholder groups (health care providers n =11 and policy makers n = 9), we sought to identify areas of convergence and divergence about what youth-orientated services and policies would be effective in Zimbabwe. Qualitative data were analyzed iteratively and thematically. Results The findings are presented to align with four levels of a socio-ecological framework: individual, community, health system and policy. All three stakeholder groups highlighted the unmet mental health and TB literacy needs of AYA, which are particularly acute early in their TB care journey, as well as the imperative of engendering family support and securing the continuity of educational or employment opportunities during and after receiving TB care. There was a consensus that clinical services needed to become more youth-centered by extending training for health care providers and investing in peer-delivered psychosocial support. More broadly, there was also a strong consensus that adolescent-specific TB policies require further development and implementation, accompanied by community-based TB education and awareness campaigns to emphasize the curability of TB and to reduce TB related stigma. Conclusions There is much to be done to improve TB care for AYA. We found that there is need for align- ment on where investment is needed to support the development of context-appropriate and effective interventions. There is an opportunity to benefit from translational learning from other successful approaches, such as HIV, within the region. Implementation of evi- dence-based interventions and youth-friendly policies and programs are much needed to improve outcomes for AYA with TB.

BackgroundSimilar to other low and middle-income countries, Ethiopia faces limitations in using local health data for decision-making.We aimed to assess the effect of an intervention, namely the data-informed platform for health, on the culture of data-based decision making as perceived by district health office staff in Ethiopia's North Shewa Zone.MethodsBy designating district health offices as 'clusters', a cluster-randomised controlled trial was implemented. Out of a total of 24 districts in the zone, 12 districts were allocated to intervention arm and the other 12 in the control group arms. In the intervention arm district health office teams were supported in four-monthly cycles of data-driven decision-making over 20 months. This support included: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritizing; and (e) a consultative process to develop, commit to, and follow up on action plans. To measure the culture of data use for decision-making in both intervention and control arms, we interviewed 120 health management staff (5 per district office). Using a Likert scale based standard Performance of Routine Information System Management tool, the information is categorized into six domains:- evidence-based decision making, emphasis on data quality, use of information, problem solving, responsibility and motivation. After converting the Likert scale responses into percentiles, difference-in-difference methods were applied to estimate the net effect of the intervention. In intervention districts, analysis of variance was used to summarize variation by staff designation.ResultsThe overall decision-making culture in health management staff showed a net improvement of 13% points (95% C.I:9, 18) in intervention districts. The net effect of each of the six domains in turn was an 11% point increase (95% C.I:7, 15) on culture of evidence based decision making, a 16% point increase (95% C.I:8, 24) on emphasis on data quality, a 20% point increase (95% C.I:12, 28) on use of information, a 21% point increase (95% C.I:13, 29) on problem solving, and a 10% point increase (95% C.I:4, 16) on responsibility and motivation. In terms of variation by staff designation within intervention districts, statistically significant differences were observed only for problem solving and responsibility.ConclusionThe data-informed platform for health strategy resulted in a measurable improvement in data use and structured decision-making culture by using existing systems, namely the Performance Monitoring Team meetings. The intervention supported district health offices in identifying and solving problems through a structured process. After further research, DIPH intervention could also be applied to other health administration and facility levels.Trial registrationClinicalTrials.gov ID: NCT05310682, Dated 25/03/ 2022.