National Strategy for Newborn andChild Survival in Ethiopia
2015/16-2019/20

Maternal and Child Health DirectorateFederal
Ministry of Health

JUNE 2015
Addis Ababa, Ethiopia

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

National Strategy for Newborn and Child
Survival in Ethiopia(2015/16 – 2019/20)

Maternal and Child Health Directorate
Federal Ministry of Health

JUNE 2015
Addis Ababa, Ethiopia

1Table of Contents
Table of Contents .................................................................................................................. 1
ACRONYMS ........................................................................................................................... 5
FOREWORD ........................................................................................................................... 6
ACKNOWLEDGEMENTS .......................................................................................................... 8
EXECUTIVE SUMMARY ........................................................................................................... 2
1. INTRODUCTION AND RATIONALE ....................................................................................... 5
2: BACKGROUND ................................................................................................................... 7
3: NEWBORN AND CHILD HEALTH IN ETHIOPIA .................................................................... 10
3.1 The Health System .................................................................................................................. 17
3.1.1 Primary Level Health Care .......................................................................................................... 19
3.1.2 Community Empowerment, Engagement and Participation ..................................................... 19
3.1.3 Secondary and Tertiary Level Health Care ................................................................................. 20
3.2 Management and Support ...................................................................................................... 21
3.3 Health Service Quality............................................................................................................. 21
3.4 Health Care Financing ............................................................................................................. 22
3.4.1 Total Health Expenditure ..................................................................................................... 22
3.4.2 Financing Channels and Arrangement .................................................................................. 23
3.4.2 Health insurance .................................................................................................................. 24

4: NEWBORN AND CHILD SURVIVAL STRATEGIC FRAMEWORK ............................................. 25
4.1 Vision ..................................................................................................................................... 25
4.2 Goals ...................................................................................................................................... 25
4.3 Objectives .............................................................................................................................. 25
4.4 Guiding Principles ................................................................................................................... 26

5: KEY NEWBORN AND CHILD SURVIVAL INTERVENTIONS .................................................... 27
5.1 Target conditions for child survival .......................................................................................... 27
5.2 Priority High Impact Interventions for newborn and child survival ........................................... 30
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

6: SERVICE DELIVERY LEVELS AND STRATEGIES ..................................................................... 36
6.1.1 Community Based Interventions .......................................................................................... 39
Essential medicines, commodities and logistics ................................................................................. 39
Capacity of HEWs ................................................................................................................................ 39
Provide counseling and care at home and health posts ..................................................................... 39
Monitoring, supervision and reporting ............................................................................................... 39
6.1.2 Population Oriented Outreach Services ................................................................................ 40
Essential medicines, commodities and logistics ................................................................................. 40
Capacity of Health workers and HEWs ............................................................................................... 40
Provision of outreach counseling and care ......................................................................................... 40
Monitoring and supervision ................................................................................................................ 40
6.1.3 Individual Oriented Clinical Services ..................................................................................... 40
Essential medicines, commodities and logistics ................................................................................. 41
Capacity of Health workers ................................................................................................................. 41
Infrastructure ...................................................................................................................................... 41
Provision of individual oriented clinical care ...................................................................................... 41
Monitoring and evaluation ................................................................................................................. 42
6.2.1 Community Based Interventions .......................................................................................... 43
Availing essential medicines, commodities and logistics.................................................................... 43
Capacity building for HEWs ................................................................................................................. 43
Community empowerment and demand creation ............................................................................. 43
Provision of basic family-level counseling and curative services........................................................ 43
6.2.2 Population Oriented Outreach Services ................................................................................ 44
Essential medicines, commodities and logistics ................................................................................. 44
Capacity of Health workers and HEWs ............................................................................................... 44
Provision of outreach counseling and care ......................................................................................... 44
Monitoring and supervision ................................................................................................................ 44
6.2.3 Individual Oriented Clinical Services ..................................................................................... 44
Essential medicines, commodities and logistics ................................................................................. 44
Capacity of Health workers ................................................................................................................. 452

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Provision of individual oriented clinical care ...................................................................................... 45
6.3.1 Community Based Interventions .......................................................................................... 46
Community empowerment and Demand Creation ............................................................................ 46
6.3.2 Population Oriented Outreach Services ................................................................................ 47
Community mobilization for services uptake ..................................................................................... 47
6.3.3 Individual Oriented Clinical Services ..................................................................................... 47
6.4 Supporting Strategies.............................................................................................................. 48
6.4.1 Resource mobilization................................................................................................................ 48
6.4.2 Human Resources for Health ..................................................................................................... 48
6.4.3 Logistics Management ............................................................................................................... 49
6.5 Implementation of the Strategy .............................................................................................. 50
6.5.1 Health care for the newborns and children in regions requiring equitable development andspecial population segments, including pastoralist and cross-border mobile communities ............. 50
6.5.2 Public Private Partynership for implementation of the Newborn and Child Survival Strategy . 51
6.5.3 Intersectoral and MultiSectoral Co-opration for implementation of the Newborn and Child
Survival Strategy .......................................................................................................................... 51

7: PARTNERSHIPS, ROLES & RESPONSIBILITIES ..................................................................... 52
7.1 Partnerships for the Newborn and Child Survival in Ethiopia .................................................... 52
7.2 Roles and Responsibilities ....................................................................................................... 53
Federal Ministry of Health .................................................................................................................. 53
National Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) and Nutrition
Technical Working group .................................................................................................................... 53
National Newborn and Child Survival Sub-Technical Working Group ................................................ 54
Regional RMNCAH & Nutrition Technical Working Group ................................................................. 54
Woreda RMNCAH & Nutrition Committee ......................................................................................... 55
Kebelle Health Development Team .................................................................................................... 55
Health Development Army ................................................................................................................. 56
Health Facilities (health Centers & Hospitals) .................................................................................... 56
Health Training Institutions & Professional Associations ................................................................... 56
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

8: MONITORING & EVALUATION .......................................................................................... 58
8.1 Regular performance tracking system ..................................................................................... 58
8.2 Operations research, studies and evaluation. .......................................................................... 59

9: COSTING AND IMPACT ESTIMATION ................................................................................ 60
9.1 Costing methodology .............................................................................................................. 61
9.3 Costing results ........................................................................................................................ 62
9.4 Limitations of current cost estimates ...................................................................................... 63

10: REFERENCES .................................................................................................................. 64
11: ANNEXES ....................................................................................................................... 67
ANNEX 1 - Intervention packages and selected indicators for monitoring the strategy .......... 674

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

ACRONYMS

AIDS
ANC
CDC
C-IMCI
DHS
ENA
EPI
FDRE
FMoH
HAD
HAPCO
HEP
HIV
HMIS
HSDP
HSTP
ICC
IEC
IMNCI
IMR
IYCF
KMC
JSC
LB
MCH
MDG
MMR
NCHS
NIDs
NMR
PMTCT
PHCU
PHC
RHBs
SDPRP
SIAs
SNIDs
SNNPR
TT

Acquired Immune Deficiency Syndrome
Antenatal Care
Communicable Disease Control
Community Integrated Management of Childhood Illnesses
Demographic and Health Survey
Essential Nutrition Action
Expanded Program on Immunization
Federal Democratic Republic of Ethiopia
Federal Ministry of Health
Health Development Army
HIV/AIDS Prevention and Control Office
Health Extension Package
Human Immunodeficiency Virus
Health Management Information System
Health Sector Development Program
Health Sector Transformation Plan
Interagency Coordinating Committee
Information Education Communication
Integrated Management of Newborn and Childhood Illnesses
Infant Mortality Rate
Infant and Young Child Feeding
Kangaroo Mother Care
Joint Steering Committee
Live births
Maternal and Child HealthMillennium Development Goal
Maternal Mortality Ratio
Newborn and Child Survival Strategy
National Immunization Days
Neonatal Mortality Rate
Prevention of Mother to Child Transmission
Primary Health Care Unit
Primary Health CareRegional Health Bureaus
Sustainable Development & Poverty Reduction Program
Supplementary Immunization Activities
Sub-National Immunization Days
Southern Nations & Nationalities and Peoples Region
Tetanus Toxoid5National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

FOREWORD
Ethiopia has made impressive progress through achiving many of the national and global healthindicators as a result of strong leadership of the Federal Ministry of Health (FMOH),
coordination of efforts and intensive investment in the health system by the government,
partners and the community at large. The country achieved MDG 4 target in 2012 three years
ahead of 2015 by reducing under-five mortality by two thirds from its 1990 level. The National
Child Survival Strategy (2005 – 2015) and the Child Survival Partnership were instrumental in
guiding the design, implementation,coordination, monitoring and evaluation of high impact
newborn and child health intervetnions in the country.
Whilst celebrating the achivements made through successful implementation of the National
Child Survival Strategy (2005 – 2015) FMOH dully recognizes that the current under-five andneonatal mortality rates of 64 and 29 per 1,000 live births, respectively, is unacceptably high.
The ministry also acknowledges that neonatal mortality rate is disproportionally highaccounting to 44% of under-five deaths. In addition, neonatal and under-five mortality rates
vary across income, gender, and geographical areas. Cognizant of this Ethiopia has envisioned
to end all preventable newborn and child deaths by 2035. To this effect in 2012 Ethiopia has led
the development of the “Promise Renewed Child survival Roadmap” with a commitment to end
preventable child death with the goal of dropping under-five mortality rate to less than
20/1,000 live births by 2035.
Effective coverage for life saving high impact newborn and child health interventions has beensteadly increasing. However, the access to and utilization of the interventions have not been
uniform across all sections of the the population and different geographical areas. Building on
the success recorded in accelerated expansion of the health services throughout the country
through implementation of the four cycles of Health Sector Development Plans (HSDPs) FMOH
will work with Regional Health Bureaus (RHBs) and its health development partners to ensure
universal coverage of quality high impact newborn and child survival interventions. Addressing
inequity and ensuring quality service delivery, prioritized guiding priniciples in the Health Sector
Transformation Plan (HSTP) 2015/16 – 2019/20, will also guide the implementation of thisstrategy.
The National Newborn and Child Survival Strategy (2015/16-2019/20), which will be part of the
HSTP covering same period, aims to reduce under five mortality from 64/1,000 live births (2013level) to 29/1,000 live births, infant mortality rate from 44/1000 live births to 20/1000 live
births and NMR from 28/1,000 live births to 11/1,000 live births. The strategy plans to ensure
universal coverage of quality high impact newborn and child health interventions along withmeaningful community empowerment to create demand for the services.
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

The strategy identified and prioritized 39 high impact and cost effective newborn and childsurvival interventions with key guiding principles for implementation of the strategy including
equity and accessibility; community engagement, empowerment and ownership; integration;
partnership; efficient use of resources; innovation and use of technology; evidence based
decision making; and provision of quality MNCH services. A sustained government andpartner’s commitment, the Primary Health Care Unit with its home grown innovative Health
Extension Program that utilizes the Health Development Army as platform for social
mobilization, and strengthened referral and linkage will continue to be the basis for continued
gains in newborn and child health.

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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

ACKNOWLEDGEMENTS
The Federal Ministry of Health would like to acknowledge the National Child Survival Technical
Working Group for their invaluable technical contributions throughout the development of the
National Newborn and Child Survival Strategy (2015/16 – 2019/20).
The Ministry would like to extend a special acknowledgement to the following institutions andpartners that provided professional experts and other support during the development of thestrategy document.
FMOH – diferrent directorates
AAU/ SPH
EPS
USAID/Ethiopia
UNICEF/Ethiopia
UNICEF/ESARO
WHO/Geneva
WHO/AFRO

WHO/Ethiopia
Save the Children International
IFHP/Ethiopia
JSI/L10K
MANHEP
PATH/Ethiopia
Water Aid/Ethiopia

8National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

EXECUTIVE SUMMARY
In Ethiopia, under-five mortality rate has declined by two thirds from the 1990 figure of
204/1,000 live births to 68/1,000 live births in 2012, thus meeting the target for Millennium
Development Goal 4 (MDG 4) on child survival three years ahead of time. In absolute numbers
the under-five deaths in Ethiopia has declined from nearly half a million, 444,000 a year in
1990, to about 196,000 in 2013. However, the mortality reduction was not uniform across thedifferent childhood age groups, geographic and socio-demographic population groups.
Disaggregation of the mortality data by age reveals that the decline in neonatal mortality is not
as impressive as the infant and child mortality figures. It has fallen only by 42% during the same
period; from 54/1000 live births in 1990 to 28/1000 live births in 2013. About 44% of thechildhood deaths occur within the first 28 days of life, thus increasingly accounting for a larger
proportion of the under five deaths. There is also wide geographic variation in under-five
mortality according to the EDHS 2011 ranging from as low as 53/1000 live births in Addis Ababa
to as high as 169/1000 live births in Benishangul-Gumuz region. Similarly, significant variation is
also observed among different socio-economic groups within the same geographic areas.
Over two-thirds of childhood deaths in Ethiopia are caused by few and easily preventableconditions; mainly infections, neonatal conditions and malnutrition. The major direct causes ofunder five mortality, based on the 2014 WHO/CHERG estimates are pneumonia (18%), diarrhea(9%), prematurity (11%), newborn infection (9%), asphyxia (14%), injury (6%), measles (2%),
malaria (3%), congenital anomalies (4%), HIV (2%), and others (21%). Under nutrition is a major
underlying cause contributing to nearly half of childhood deaths. Even though underweight,
stunting and wasting has declined by 39%, 31% and 25% respectively during the last 15 years,
the 2014 mini EDHS estimates of stunting (40%), underweight (25%) and wasting (9%) are still
very high.
The MOH developed the first comprehensive National Child Survival Strategy (2005-2015) in2005 which was being implemented as part of the 3 rd and 4th HSDP cycles. The implementationof this strategy had boosted the child survival efforts of the country through improved
coordination, partnership, resource mobilization and scale up of high impact interventions. As aresult of these efforts, Ethiopia has recorded significant reduction in childhood mortality andhad achieved the MDG4 target in 2012. Several factors are believed to contribute to the
reduction in under five mortality including the improvement in overall socio-economic status
and the significant increase in access to primary health care services, from 68% in 2005 to 92%
in 2010. In terms of interventions; reductions in malnutrition, increases in vaccination, Vitamin
A, ITNs, family planning and water & sanitation were the main contributors for the
improvements in child survival in the last two decades.

2National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Even though 2005 – 2015 National Strategy for Child Survival provided the means for achieving
the MDG4 goal, several global and national developments had happened during the last eight
years necessitating revision of the strategy. A number of new interventions including
community management of childhood illness (pneumonia, diarrhea, malaria, malnutrition) andneonatal sepsis (CBNC), community based nutrition (CBN), Heamophlusinflueanza type b
vaccine, hepatitis vaccine, Pneumococcal & Rota virus vaccines, and “Option B+” for PMTCT,
were already introduced. Other new high impact interventions including corticosteroids forpreterm labor at hospital level and chlorhexidine for cord care at community and facility levelare in the process of introduction to address the high neonatal mortality.
There is also a need to scale up existing high impact interventions whose population coveragelags behind the target such as skilled birth attendance & early postnatal care; and treatment
interventions including ORS & Zinc, antibiotics for pneumonia, ACT for malaria and ART for HIV
infected children. In line with the current focus on facility delivery, clean and safe delivery by
HEW is no longer included in the list of newborn and child survival interventions in areas where
there are accessible health centers.
Thus, the revision of the current strategy was imperative to consolidate the encouraging gains
in child survival and the long-term vision of the country to end all preventable child deaths by
2030.
The goal of this National Newborn and Child Survival Strategy (2015-2020) is to reduce underfive mortality from 64/1,000 (2013 level) to at least 29 /1,000, infant mortality rate from44/1000 to 20/1000 and NMR from 28 to 11/1,000 by 2020.
This strategy would be implemented in line with other relevant national strategic plansincluding; HSTP (HSDP V), the Roadmap for Accelerated Reduction of Maternal and Newborn
Mortality, the National Nutrition Program, the EPI Comprehensive Multi-Year Plan, the National
strategic Plan for Malaria Prevention Control & Elimination, the National strategic Plan for
Elimination of MTCT of HIV, One WASH National Program, iCCM and CBNC implementation
plan. The strategy is also linked to the post MDG agenda – the commitment of government ofEthiopia for ending preventable child mortality in a generation time.
The key guiding principles for implementation of the revised strategy focus on: equity andaccessibility; community engagement, empowerment and ownership; efficient use ofresources; innovation and use of evidence based interventions, provision of quality MNCH
services, strong monitoring and dissemination of best practices.
A package of 34 high impact and cost effective newborn and child survival interventions areprioritized with coverage targets for 2019/20. The continuum of care approach will be used to3National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

rollout the delivery of the selected high impact newborn and child health intervetions
addressing particular needs of women and children across time (pre-pregnancy, pregnancy,
delivery, postnatal period, infancy and childhood) and the different mix of the interventions arepackaged to be delivered at household/community, population oriented outreach services andindividualized clinical care levels. In rural area health posts, health centers and primary
hospitals will serve as service delivery points while the health development army platform will
be used to empower and engage the community. In urban areas the first entry to the healthsystem will be health centers that will provide basic and emergency care for communities,
hospitals will serve as referral facilities for advanced newborn and child health care. Healthdevelopment army working hand in hand with the urban health extension workers will be thecrucial community networks that will mobilize communities and engage them in the planningand implementation newborn and child health services in urban. The strategy emphasizes theneed for intensified effort in regions requiring equitable development to address the visible gap
in survival and development of newborns and children across regions.
Optimal implementation of the key interventions will prevent deaths of 415,688 and 210,234
under-five and neonatal deaths, respectively, over the period of five years. Optimal
implementation of the selected newborn and child survival interventions requires mobilizing a
total of US$ 1.16 billion (ETB 23.2 billion) in five year period. Existing funding channels (channel
1a, channel 1b, channel 2 and channel 3) will continue to be used as financing arrangement in
the implementation the intervetions through direct funding by the government or by healthdevelopment partners. In addition, the FMOH will strengthen its effort to expand the fund baseof the Technical Assistance Pooled Fund and will work with the health development partners tocontinue the MDG Performance Fund after the end of the MDG period in some form or shape.
FMOH will also work with regional governments and health bureaus to scale up the Community
Based and Social Health Insurance schemes to insure financial sustainability of the healthsystem.
National newborn and child survival partnerships and coordination platforms will bestrengthened at all levels (from national to Wereda levels) under the leadership of the FMOH.
Structures to scale up selected newborn and child survival interventions will be strengthened
through harmonization of efforts and mobilization of needed resources. Progress will bemonitored annually using standard indicators. HMIS, population surveys including the EDHS in2015 and 2020 will be used to monitor progress over years and evaluate achievement of theplanned targets.

4National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

1. INTRODUCTION AND RATIONALE
Ethiopia has made considerable progress in reducing under-five mortality rate. According to the2014 UN Inter-agency Group for Child Mortality Estimation (UN-IGME) report, Ethiopia is one of
the eight high-mortality countries (together with Bangladesh, Malawi, Nepal, Liberia, United
Republic of Tanzania, Timor – Leste, Niger and Eritrea) where the under 5 mortality has
declined by two thirds, thus achieving MDG4 three years ahead of the 2015 deadline (UNIGME,2014). However, children still continue to die of easily preventable and treatable diseases forwhich low cost and effective interventions exist. In addition, there has not been significant
reduction in neonatal mortality(WHO, 2014). Much remains to be done to maintain gains in thelast two decades and accelerate progress to reach post MDG targets, thus calling for a revisionof the current child survival strategy.
The National Strategy for Child Survival developed in 2005, provided platform for
implementation of key interventions to reduce child mortality in line with achieving themillennium development goal related to reduction of child deaths by two third. Since its
development in 2005 several evidence-based interventions that need to be incorporated in thestrategy have been initiated. These include community management of pneumonia throughIntegrated Community Case Management (iCCM); community based newborn sepsis
management through the Community Based Newborn Care (CBNC); Newborn Intensive Care
Unit (NICU); Newborn Corner; introduction of Hemophilus Influenzae, Pneumococcal, and Rota
virus vaccines to EPI; and shift of PMTCT to “Option B+”.
Moreover, a changing landscape due to population dynamics, urbanization, double burden ofcommunicable and non-communicable diseases as well as malnutrition, industrialization,
globalization, climate change and technologies indicate the need for continuous update ofglobal and national strategies. It is therefore necessary to develop a follow up newborn andchild survival strategy in light of the new high impact interventions and priority target groups,
service delivery approaches and aligning with international and national policies and strategies.
Above all, the strong political commitment to consolidate the encouraging gains in child survival
and the long-term vision to end preventable newborn and child deaths necessitated the needfor development of a comprehensive newborn and child survival strategy ahead of the life spanof the 2005 – 2015 strategy(FMOH, 2005). In the current strategy more emphasis is given tointerventions addressing priority causes of newborn mortality and improving nutritional statusof children.
Thus, the new strategy fine tunes, contextualizes and incorporates high impact newborn andchild survival interventions and service delivery models that have gained global acceptance,
keeping the primary healthcare approach at the core. The service delivery model will be basedon life cycle approach and ensuring continuum of care across time: adolescence, pre5

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

pregnancy, childbirth and postnatal period, childhood and through reproductive age andservice delivery levels: at home and community level, through primary and referral careservices of health facilities. The strategy also ensures linkage across maternal, newborn andchild health service delivery points within health facilities with the aim of avoiding missed
opportunities and provision of comprehensive service for newborns and children. This approachis based on the sound premise that health of an individual across the life stages and levels ofdelivery are interlinked.
The development of this strategy is informed by the child survival situation analysis that
identified critical factors, bottlenecks and solutions. The strategy also builds upon the 2005 –2015 National Child Survival Strategy to consolidate gains from successful interventions andstrengthens effective universal coverage for proven existing interventions. The strategy isdeveloped around strengthening the health care system, giving priority to universal coveragewith special focus on addressing inequity in access to and utilization of newborn and childhealth services and improvement of quality of services together with community mobilization
for demand creation and utilization of health services. The strategy also fosters multi-sectoral
and interdepartmental collaborations and partnership of all stakeholders that share common
goals and vision for improved health outcomes with emphasis on the most vulnerable andunderserved sections of the population. The strategy builds and aligns with strategies andvision such as HSDP, HSTP, GTP and supporting programmatic strategies of other sectors.

6National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

2: BACKGROUND
Ethiopia is situated in the horn of Africa covering about 1.1 million square kilometers area. The
country shares border with Djibouti, Eritrea, Kenya, Somalia, South Sudan and Sudan. It has
great geographical diversity, with high peaks ranging from 4,550m above sea level to low
depressions of 110m below sea level. There are topographic-induced climatic variations broadly
categorized into three: the “Kolla”, or hot lowlands, below approximately 1,500 meters, the“Wayna Degas” at 1,500-2,400 meters and the “Dega” or cool temperate highlands above 2,400
meters. More than half of the country lies above 1,500 meters. Malaria transmission in Ethiopia
occurs mainly in areas up to 2000 meters, which accounts for about 75% of the total landmass.
Ethiopia is the second most populous country in Africa with a total population of 90.1 million, of
which more than 84% live in rural areas. It has a broad geographic spectrum and over 80
distinct ethnic groups. Ethiopia’s population is young with 45% being under the age of 15 and14.6% (13.2 million) being under the age of 5. About 23.4% of the population is women of
reproductive age(FDRE, 2008). The average household size is 4.8 people, with the urban
population having a smaller mean household size (3.6) than the rural population (5.1) (CSA,2014). Life expectancy at birth is 64 for both sexes with 65 years for women and 62 years formen (WHO, 2014).
Ethiopia has a federal system ofgovernment. The country is divided intonine administrative regions: Afar, Amhara,
Benishangul-Gumuz,
Gambela,Harari,
Oromiya, Somali, Tigray, and the Southern
Nations, Nationalities and Peoples Region(SNNPR); as well as two city administrations,
Addis Ababa and Dire Dawa. The regions are
divided into zones, woredas, and kebeles
which is the lowest level of administration.
The woreda is the most important local
government structure, acting as the basis formost administration and management.
Currently there are 956 woredas,
representing around 100,000 people eachand 16,541 kebele (FMOH, 2014/15), withaverage catchment populations of 5,000
people each.
As part of the effort to transform the country’s economy and raise people out of poverty theFederal Democratic Republic of Ethiopia developed and implemented successive national
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

poverty reduction programs including the Sustainable Development and Poverty Reduction
Program (SDPRP), Plan for Accelerated and Sustained Development to End Poverty (PASDEP)
and the recent Growth and Transformation Plan (GTP). Through implementation of these
programs the country registered continuous economic growth and expanded coverage andutilization of social services. The common guiding principles enshrined in the poverty reduction
programs are ensuring faster and equitable economic growth; maintaining agriculture as amajor source of economic growth; enhancing expansion and quality of infrastructuredevelopment (road, water supply, electricity) and improving access to education with emphasison girls and women enrollment. The gains recorded through implementation of the poverty
reduction programs have largely contributed to the improvement of health and survival ofmothers, newborns and children.
The 1993 Health Policy, founded on general principles of democratization and decentralization,
has decentralized the authority in the health system through transfer of the major parts ofdecision making, health care organization, capacity building, planning, implementation andmonitoring of health programs to regions and districts. Accordingly, the FMoH is primarily
responsible for policy and guideline development and provision of technical support while themanagement, coordination, and administration of health services are the responsibilities
shared between Woreda Health Offices (WrHOs) and Regional Health Bureaus (RHBs).
Since 1997 four successive Health Sector Development Plans (HSDPs), which are aligned withthe country’s poverty reduction programs, have been developed and implemented to execute
key priority interventions envisioned in the national health policy. As part of the second phaseof the Growth and Transformation Plan (GTP) 2015 – 2020, the government is in the process ofdeveloping the Health Sector Transformation Plan (HSTP), 2015 – 2020, with explicit goals andtargets that directly and indirectly contribute to the survival and development of newborns andchildren. In addition, Ethiopia has led the development of the “Promise Renewed Child survival
Roadmap” in 2012 with a commitment to end preventable child death with the aim of bringing
down the under-five mortality rate to less than 20/1,000 live births by 2035.
To achieve the aforementioned HSDPs, FMOH has developed different strategies and programs.
Some of the strategies and policies that have been adopted by the FMOH and have direct
impact in improving maternal, newborn and child survival include Adolescent and Youth
Reproductive Health Strategy, Sexual and Reproductive Health Strategy, Elimination of Motherto Child Transmission of HIV (PMTCT/HIV) Strategy, Maternal and Newborn Health Roadmap,
Malaria Control Strategy, EPI Strategy, National Nutrition Strategy, Stunting Reduction Strategy,
and Infant and Young Child Feeding (IYCF) Strategy.
There are also programmatic strategies targeting child survival at health facility and community
level in the country such as Integrated Management of Neonatal and Childhood Illness (IMNCI),
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Integrated community case Management (ICCM), Community Based Neonatal Care (CBNC),
Newborn Corner Initiative, Neonatal Intensive Care Unit (NICU), Pediatric Referral Care,
Nutrition Program, Expanded Program of Immunization, Prevention of Mother-to- Child
Transmission of HIV (PMTCT) and Pediatric ART, Maternal Health Programs, and Health Service
Quality Improvement Program.
The health care delivery system in Ethiopia is organized in three-tier system. The primary level
health care delivery system in rural setting includes five Health Posts associated with HealthCenters and Primary Hospital. In urban setting the the Health Center is primary entry point to
the health system. The secondary level health care includes General Hospitals and tertiary level
health care include Tertiary Hospitals. As more than 80 percent of the Ethiopian population
resides in the rural part of the country, the HSDPs have given more focus to the primary healthcare units while strengthening the referral care at secondary and tertiary levels.
Ethiopia’s flagship Health Extension Program (HEP) is the platform for delivery of community
based basic promotive, preventive and curative health services. Two Health Extension Workers(HEWs), based in the health posts that serve an average of 5,000 populations, are the primarypoint of entry to the health system for the rural community. HEWs, supported by the Health
Development Armies (HDAs) – a network created between five households and one modelfamily to influence one another in practicing healthy life style, work to empower thecommunity to generate its own health. They provide set of preventive, promotive and curative
health services packaged in four programmatic areas: the Family Health Services; Disease
Prevention and Control; Environmental Hygiene and Sanitation; and Health Education andCommunication. They serve as the backbone of the Primary Health Care Units (PHCUs) acting as
the most important frontiers for newborn and child survival in the country.
The Newborn and Child Survival Strategy will be implemented in line with the national policies
and strategies discussed above and with the long-term goal of eliminating all preventablechildhood deaths by 2035.

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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

3: NEWBORN AND CHILD HEALTH IN ETHIOPIA
Trends of newborn and under five mortality
The 2014 UN Inter-agency Group for Child Mortality Estimation (UN-IGME) report estimatedthat Ethiopia’s under five, infant and neonatal mortality rates were 64, 44 and 28 per 1000 live
births, respectively. The child mortality trends in Ethiopia show a steep decline; from 1990 to2000 with the average annual reduction (ARR) of U5MR at 2%, but the reduction rate
accelerated to 5% after 2000, bringing about a dramatic decrease in under five mortality rate to
the current level of 64/1000 live births in 2013. Thus in August 2013 Ethiopia was declared tohave achieved MDG 4 (UN-IGME, 2013). Figure 1 shows the trend in under-five, infant and childmortality since 1990.
Figure 1: Trends in under-five, infant and neonatal mortality rates and estimated levels for 2015

(Source: EDHS 2000, 2005 and 2011 & IGME 2014 report)

Socio demographic determinants of newborn and under-five mortality
Despite the success Ethiopia recorded in reducing under-five mortality rates still an estimated
196,000 (NU-IGME, 2014) children are currently dying each year and the reductions in mortality
were not proportionate across the different childhood age groups, socio-economic strata andgeographic regions of the country. There is strong association of newborn and child mortalities
10National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

with wealth, maternal educational status, residence, maternal fertility characteristics andaccess to safe water and sanitation.
According to the 2011 EDHS, the under five mortality among the poorest 20% the population(137/1000) was 1.6 times that of the wealthiest 20% of the population (86/1000). For childrenof mothers with at least secondary education it was 46/1000, but for children of mothers withno education it was 121/1000, 2.6 times as high as with that of children of mothers with at least
secondary education and more than 5 times as high as that of mothers with more than asecondary education (24 per 1,000 live births). Likewise, for children who live in urban areas themortality rate was 83/1000, whereas the rate for rural children was 114/1000, 1.4 times as highas that of the mortality rate for urban children. There was also wide regional variation in
mortality with U5MRs ranging from as low as 53 in the capital city of Addis Ababa to as high as
169 in Benishangul-Gumuz and 127 in Afar, the two developing regional states of the country(CSA, 2011).
Figure 2: Regional variation in under-five mortality, EDHS 2011

Low total fertility rate (TFR) impacts child survival by bringing optimum spacing between
successive pregnancies. Birth intervals of less than two years are associated with a higher
mortality of newborn and children. In the 2014 mini EDHS report the TFR for Ethiopia wasestimated at 4.1 children per woman with 4.6 and 2.3 children per woman in rural and urban
11National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

areas, respectively (CSA, 2014). According to the 2011 EDHS report, children born within lessthan two years after the preceding birth are 2.5 times likely to die within the first year of life
(CSA, 2011).
Access to improve sanitation and water supply is associated with lower risk of mortality among
under-five children. Based on the further analysis of DHS surveys from 171 countries
representing data of 1.1 million under-five children access to improved sanitation was
associated with lower risk of child mortality (OR=0.77, 95% CI of 0.68 – 0.86) (Gunther F. et al2011).
Causes of Newborn and Child Mortality
The major causes of under five mortality, based on the 2014 WHO/CHERG estimates for
Ethiopia (Figure 3), were acute respiratory infection (ARI) (18%), diarrhea (9%), prematurity(11%), sepsis (9%), birth asphyxia (14%), injuries (6%), and measles (2%) and others (21%)(Count Down to 2015, 2014).
Figure 3: Causes of Under-five mortality, Ethiopia(Source: WHO/CHERG 2014)

Malnutrition is a major contributor to child mortality in Ethiopia being an underlying cause fornearly 45% of under-five deaths(Lancet 2013). According to the 2014 mini EDHS, 40% of allchildren under five were stunted and about 18% percent were severely stunted. Nine percent
12National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

were wasted and 3% severely wasted. Nutritional status also varies greatly by region, with thehighest level of stunting rates being in Tigray, Amhara, Afar and SNNP regions. Figure 4 shows
the trend in under nutrition during the last decade (CSA, 2014).
Malnutrition is also widespread among Ethiopian women (CSA, 2011). The 2011 EDHS revealed
that the level of chronic malnutrition among women in Ethiopia is high, with 27 percent of
women either thin or undernourished—that is, having a body mass index (BMI) of less than
18.5 kg/m2. It appears that malnutrition remained high with small decline over the last decade.
The few previous studies in Ethiopia also found a similarly high prevalence of low BMI in therange of 16%-32%. Regional variation in the prevalence of under-nutrition among women has
been apparent; in some regions such as Afar and Gambella rates exceeding 40% were recorded.
In a multivariate analysis, higher risk of underweight is significantly associated with rural
residence, living in lowland, having low education, being poor, a lack of household toilet facility
and being anemic (In depth Analysis of EDHS 2000-2011). Ethiopian Mothers are also affectedby micronutrient deficiencies. The prevalence of anemia among women in the reproductive agegroup (15–49) was found to be 17 percent. Evidences showed that fetal growth restriction ismore prevalent among malnourished and anemic mothers decreasing their chance of survival.
Figure 4: Trends in under-five nutritional status(Source: EDHS 200, 2005, 2011and mini EDHS 2014)

When are children dying?
As shown in Figure 5 below, a higher proportion (44%) of under-five deaths in Ethiopia occur
within the first 28 days of life due to the high rate of death of neonates. The majority of13

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

newborn deaths occur during the first week of life (75%), and about 25% to 40% of deaths
occur within the first 24 hours. The most common causes of death are prematurity (37%),
infection (28%), and asphyxia (24%) (Liu L. et al. 2012).
Despite Ethiopia’s remarkable reductions in infant and under-5 mortality and achievement of
MDG four three years ahead of the deadline, the reduction in neonatal mortality has not been
as impressive. Neonatal mortality has been stagnant over the past five to ten years withneonatal mortality accounting for 44% of the under 5 mortality and over half of infant deaths.
The IEGM 2014 estimate indicated that there is a further decline in U5MR, IMR and NMR of 64,
44 and 28/1000 live births, respectively but the proportion of newborn death is still high.
To achieve significant reduction in newborn mortality it is important to give due emphasis toneonatal health problems that are readily preventable or treatable with proven, cost-effective
interventions that can significantly contribute to the reduction of under-five mortality by 2020and beyond. Newborns will benefit from the already introduced high impact interventions that
include iCCM, CBNC, “Option B+” for PMTCT, and other interventions that will be introduced,
including corticosteroids for preterm labor and chlorhexidine for cord care. There is also a needto scale up existing high impact interventions whose population coverage lags behind the target
such as skilled birth attendance & early postnatal care that will significantly contribute to the
reduction of neonatal mortality.
Figure 5: When are Children Dying?

(Source:IGME 2014 Estimates)

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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Ethiopia has been implementing key neonatal and child survival interventions, however,
coverage of services remains low for most of the interventions. Figure 6 shows the trend of
selected newborn and child survival interventions since 2005. Evidently, significant
improvements in coverage had been observed primarily in preventive interventions including
contraceptives, immunizations, vitamin A, ITN, water and sanitation interventions. On the other
hand, care seeking for common illnesses and utilization of clinical services namely; skilledattendance, post-natal care, treatment for common illnesses including pneumonia, diarrhea,
malaria and pediatric ART/PMTCT remain low.
Barriers to MNCH service utilization are in general related to costs of transport and treatment;
access to services due to distance to health facilities and inadequate transport services,
sociocultural factors and lack of knowledge of the causes of diseases and available appropriate
treatment (Nathan P. Miller 2013, FMOH, 2014). Supply side barriers such as low quality ofhealth care services caused by unavailability of medicines, medical supplies, equipment,
adequate number and mix of skilled and committed staff result in low client satisfaction andcare seeking. Lack of functional performance monitoring system and accountability, and failure
to scale up best practices are also among the challenges to attain optimal service utilization.
Where in Ethiopia are children dying?
Further analysis of under-five deaths in Ethiopia show that three agrarian regions combined(Oromia, SNNP and Amhara) contribute to 87% of absolute number of under-five deaths in the
country, with Oromia taking the highest share (42%). However, in terms of risk of death a childborn in Benishangul Gumuz region has the highest risk of death followed by Afar, Gambella,
Ethiopia Somali and SNNP. With the same token, a child born in rural area has higher risk ofdeath compared to one born in urban area in any particular region in the country. Interventions
that aim to reduce the under-five mortality need to also target to close the gap in these evident
disparity in mortality in those different contexts.

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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Figure 6: Coverage of key neonatal and child survival interventions in 2005 and 2013/14.

Sources: EDHS 2005, EDHS 2011, mini-EDHS 2014, HMIS 2013/14, MIS 2011, ICS 2012, WASH Inventory 2012

Success factors for reduction of under-five deaths in Ethiopia
As indicated in the previous sections Ethiopia registered marked reduction in child mortality
and achieved the MDG4 target in 2012, three years ahead of the timeline. There was nonational level evaluation conducted to document factors that contributed to this success.
However, a number of factors within and outside the health care system have synergisticallycontributed towards the success the country has achieved.
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

The government of Ethiopia has brought maternal, newborn and child health as priority political
agenda and maintained its commitment to improving the health and survival of women andchildren in the country. This has been demonstrated by massively expanding access to andutilization of key health care services through HEP, government’s flagship program, and the
expansion of primary and secondary level health care through accelerated expansion of healthcenters and hospitals throughout the country. The country also managed to equip a large
proportion of these facilities with basic equipment and supplies along with staffing them withtrained health workforce that run the facilities. The health care finance (total healthexpenditure per capita) showed a paramount improvement in the last decade with introductionof new schemes including retention and utilization of revenues in the health facilities; openingof private wings in hospitals; community based health insurance and social health insurances.
As a result improvements in coverage of effective interventions to prevent or treat the mostimportant causes of child mortality was achieved; in particular essential immunizations, malaria
prevention and treatment, vitamin A supplementation, birth spacing, early and exclusive breast
feeding are some of the factors that contributed to the success (FDRE/MoH, 2014). Although it
is moderate, the country also achieved increase in coverage of skilled attendance, post-natalcare, treatment for common illnesses including pneumonia, diarrhea, malaria and pediatric
ART/PMTCT.
In addition to the successes within the health system, it is important to note the investments
made in other sectors that contributed to the survival and wellbeing of children in the country.
This has increased over years along with economic development the country has enjoyed in thelast decade. Access to and universal enrollment in primary education throughout the country
has been expanded with concurrent expansion of secondary and higher education.
Infrastructure including road, electricity and telecommunication has expanded in many folds,
and access to water and sanitation facilities improved. Agricultural productivity and foodsecurity has been improved. Women participation in leadership and political structures has
showed a significant improvement (FMOH (draft), 2014).

3.1 The Health System
Health Systems consists of all organizations, product, people and actions whose primary intent
is to promote, restore or maintain health. Ethiopia has a three-tier health care delivery system.
The primary level health care delivery system in rural setting includes five Health Posts (eachserving 3,000 – 5,000 population), Health Centers (15,000 – 25,000 Population) and primary
hospital (60,000 – 100,000 population). In urban setting the health care system is organizedwith health center as primary entry point (each serving about 40,000 population). The
secondary level health care delivery system include general hospital (1-1.5 million people) andtertiary level health care delivery system include tertiary hospital (3.5 to 5 million people)(FMOH, 2010).
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Figure 7. Three tier health care delivery system in Ethiopia

Source: FMOH HSDP IV
The Ethiopian health care delivery system is augmented by the rapid growth of the private-forprofit and NGOs sector that are playing significant role in expanding the health service coverage
and utilization. To catalyze the engagement of the private sector in health service delivery andfoster partnership between the public and private sectors the FMOH launched the Public
Private Partnership (PPP) strategy. Forums of private sectors are established focusing on quality
improvement and regulatory schemes. The PPP strategy will be an opportunity to promote andstrengthen local manufacturing of essential medicines and commodities for newborn and childsurvival interventions. This will ensure sustained availability of those commodities andsignificantly reduce the lead-time between their production and use. Currently, manufacturingof chlorhexidine and RUTF is undergoing. The private sector and NGOs also play pivotal role inensuring access to health services and products through engaging in community engagement
and social marketing. There is a need to improve the coordination and collaboration effects of
PPP as engaging and expansion of the private sector and NGOs can enhance the inter-sectorial
collaboration, and improve investment in the health sector.
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

3.1.1 Primary Level Health Care
The PHCU provides basic promotive, preventive and curative health care services to its
catchment population through participation of communities in the planning andimplementation of the health care services (FMOH, 2010).
With rapid expansion of the physical infrastructure, equipping the primary level health care(health posts, health centers and primary hospitals) throughout the country and training anddeployment of health care workers the primary level health care structure and function was
revitalized and health posts were made to administratively and technically link with the healthcenters. The mandate of the woreda health offices remained to be management andcoordination of the operation of all PHCUs within their woredas including planning, financing,monitoring and evaluation of health programs and services deliveries. To guide therevitalization of the PHCU in 2012 a guideline on ‘Primary Health Care Unit Linkage andReferral’ (FMOH, 2012) was prepared by FMOH and distributed to regions.
Expansion of the coverage of primary level care across the country has improved access andutilization of important maternal, newborn and child health services by women and children. In
addition to physical access, health facilities and health posts are incrementally expanding the
MNCH service packages they are providing. However, as much as there are increasingly more
MNCH interventions made available to women and children, the access to and utilization of theservices varies by areas and sections of population calling for working towards ensuring
universal coverage. Moreover, there are evident gaps in quality of the available services
provided in the health facilities and health posts.
3.1.2 Community Empowerment, Engagement and Participation
FMOH along with health development partners has been implementing different models of
engaging community members in the plan and implementation of health programs. Following
the launch of the Health Extension Program (HEP) in 2005 the engagement of community
members in the health service program planning and implementation became more systematicand organized (FDRE/MoH, 2007). However, the types, roles and levels of engagement of thecommunity health workers were not consistent throughout the country. Cognizant of thesechallenges and with the aim of standardizing the community health workers’ types, roles andlevel of engagement and to ensure scale up of key positive family and community healthpractices, in 2011, the government of Ethiopia launched the Health Development Army (HDA)
structure (FDRE/MoWYCA, 2014).

Health Development Army: is a network of women that are led by women who haveadopted better health behavior through completing the 16 packages of HEP. Leaders of the19National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

network of women influence women under their leadership to practice a healthy life style. Fiveof such 1-to-5 networks of women form a health development team. The leaders of the
networks are selected by the members of the network with the key criteria including being amodel family in the community through completing implementation of the 16 packages of HEP
and getting trust and respect by the members in mobilizing the community. The formation of
the health development teams and the 1-to-5 networks is facilitated by HEWs and the Kebele
administration. The HDA is designed to accomplish the following critical tasks(FMOH, 2012/13):
x Identify locally salient bottlenecks that hinder families from utilizing key services andimplementing the HEP, and prioritize those that they want to address as a teamx Come up with feasible strategies to address these problems
x Implement the strategies and evaluate their activities.
A total of 2.3 million women were organized into 442,773 health development teams
voluntarily mobilized to lead 1-to-5 networks of women throughout the country; the plan is tomobilize up to 3 million one-to-five networks of women to work alongside the HEWs in
supporting families to adopt a healthy behavior(FDRE Ministry of Health, 2014).
For regions that require equitable development, a social mobilization strategy is developed withan objective of sensitizing and mobilizing the leaders and the community at large to implement
the HEP with special focus on maternal, neonatal and child survival. There are social
mobilization committees established at all level; starting from kebele to federal level. Each of
the committees has five to seven members (including political leaders, religious and clan
leaders, health managers, party members and representatives of communities/women). The
committees use checklists to monitor performances of selected indicators, meet regularly toreview progress and make decisions and recommendations to address challenges faced. Each of
the committees has specific responsibilities and duties with reporting and feedback
mechanisms (FMOH, 2012).
Since the implementation of the strategy in regions requiring equitable development, a seriesof consultative and sensitization meetings have been conducted at regional, zonal and woreda
levels chaired by political leaders at the respective levels. At the end of each session, a clear
plan of action to cascade mobilization to kebele and household levels were developed andsigned by all parties committing to the implementation. Other subsequent sessions areorganized to assess progress and address any potential bottlenecks.
3.1.3 Secondary and Tertiary Level Health Care
Based on the recent Service Provision Assessment (SPA) conducted in Decemer 2013 in Ethiopia
there were total of 163, 73 and 35 primary, general and referral hospitals, respectively, of
which 40, 71 and 30 respectively were fully functional.
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

According to the 2013/2014 HSDP IV annual performance report the total number of healthposts reached 16,048 making functional health posts to population ratio at 1:5,264 and to datethe total number of health centers constructed reached 3,245, reaching a functional healthcenter to population ratio of 1: 26,858. The coverage of BEmONC in Health Centers and
CEmONC in Hospitals has increased to 55.8% and 82.6%, respectively (FDRE Ministry of
Health, 2014).

3.2 Management and Support
Ethiopia has a health system with decentralized decision-making powers by regions anddistricts. The mandate of the federal government is mainly developing policies, regulations, andstrategies at federal level while regions have overall responsibilities of management of thehealth service delivery, which include management of the health facilities, personnel and healthtraining institutions within the regions. As the capacity of zones and woredas became stronger
some of the tasks of the regions are being shifted to lower level and regions would focus of
overall coordination, monitoring and evaluation of the implementation of the health programsin their jurisdiction.
The FMOH has recently reformed its structure to improve its efficiency in providing countrywide leadership of the health program. The reform was reflected in the reorganization of
departments at the ministry by program and operational areas. Accordingly, five main
programs were organized under the Maternal and Child Health Directorate (Maternal Health
Program with family planning, Child Health Program, Immunization Program, Nutrition Programand PMTCT programs) and responsible FMOH experts were assigned to lead and coordinate the
MNCH activities with development partners and donors.

3.3 Health Service Quality
The FMOH acknowledges that quality of health care did not catch up with the expansion ofhealth care services in the country. Quality of MNCH care encompasses several aspects
including availability of equipment, supplies, guidelines and protocols; knowledge, skills,
training, experiences and motivation of health workers; supportive supervision facilities
receive; and satisfaction of clients with the care they received. The strategic initiatives of the
FMOH with respect to improving quality of care include improvement in the emergency
management system, regulation of non-public providers, blood transfusion provision, medicalcare SOP’s and monitoring, integration of service provision, and functional referral services.
The hospital reform agenda was launched in May 2010 with the Ethiopian Hospital Reform
Implementation Guideline (EHRIG) as the tool for the reform. Currently all public hospitals are
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

participating in the quality improvement initiative. At present, it is estimated that some 50% –70% of these standards are being regularly implemented by hospitals, with the standards
relating to outpatient services, inpatient services, and pharmacy services most effectively
implemented. Implementation of referral and nursing standards are partially being
implemented, while those most neglected are the ones relating to medical equipment andfinancial management.

3.4 Health Care Financing
Financing continues to come from multiple sources including households’ out-of-pocket
spending, the government treasury (federal, regional, district, and municipal levels), bilateraland multilateral donors and nongovernmental organizations (NGOs), private enterprises, andparastatal sources (FMOH, 2014). Though steadily growing, Ethiopia’s health spending is far
from adequate for financing of essential health care services. To address this chronic challenge
the government of Ethiopia has been working to improve efficiency of the health system toensure proper distribution and use of the available resources and mobilize additional resourcesfrom health development partners. The following strategies have also been implemented:
x The initiation and development of risk pooling mechanisms such as social healthinsurance and community-based health insurance schemes
x Retention and utilization of user fee revenues at health facility level
x Introducing private wings in the public hospitals
Informed by evidences from the Fifth National Health Account (NHA) studies conducted over
the years, the health system has undergone reforms including, retention and utilization ofrevenue, administration of the fee waiver system, establishment of a functioning facility
governance body, outsourcing of non-clinical services, establishing private wings in healthfacilities and the exemption of certain services. The assumption is that the ensuring access andutilization of quality MNCH services by women and children through the financial reforms
would largely improve the health of women and children.

3.4.1 Total Health ExpenditureThis fifth round of NHA revealed that there has been a tremendous increment in healthspending both in nominal and per capita terms. Nominally, National Health Expenditure (NHE)
increased from Birr 11.1 billion (US$1.2 billion) in 2007/08 to over Birr 26.5 billion (US$1.6
billion) in 2010/11. Per capita NHE increased modestly, from US$16.09 per capita in 2007/08 to
US$20.77 in 2010/11. This figure is far below the HSDP-IV per capita spending target of US$32.
The amount is also low compared with Ethiopia’s peer countries and much less than the US$44
per capita recently recommended by WHO.
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

The NHA report also identified proportions of health expenditure by source of financing. In rankorder, these were 49% by development partners, 34% by household out-of-pocket expenditure,
15.6% by Government (central and regional) and the rest by a combination of employer
insurance schemes and other private sources.
National Health Expenditure, at the current market price, increased by 138 percent between
2007/08 and 2010/11. Government contributions grew over time but most of the increment
came from households (34%) and donors (49%). As a result households are burdened by highout-of-pocket costs for health that usually are incurred at time of sickness. It is critical to workon sustainability of health sector financing as well as on reducing the financing burden on
households, particularly at time of sickness.
Child health is one of the priority areas in the HSDP IV but the share of spending is one of thelowest compared with the other priority areas.
HSDP IV set a target of increasing total health spending from 16.1 USD/Capita to 32.2 USD per
capita and the share of government health budget as a proportion of total government budget
from 5.6% to 15% to meet the target set by the Abuja Declaration. Although allocation for
health showed an average 3.6 billion birr per year increment the share of health from the total
government budget stood at about 8.5% over the last years of the HSDP IV implementation(FMOH, 2012/13). This has significant impact on the quality of MNCH care provided at healthfacility and community levels.

3.4.2 Financing Channels and Arrangement
Three channels of funding currently operate in the country, which also work for the healthsector. Channel 1a (un-earmarked): is used by the government itself whereby at eachadministrative level, the specialised finance bodies control the release of funds and report
upwards on their utilisation. This is also the channel that is used by donors providing budget
support and PBS component-I. Channel 1b is an earmarked fund transferred through MoFED,
with funds from each donor being tagged (with a two figure code), and sent to the region andzone/Woreda (with a location code). The funds are reported on and accounted for separately,
and used to pay only for activities agreed by the particular donor, often according to its specificprocurement and disbursement procedures. Channel 2 is a channel whereby the regional andzonal/woreda finance bodies are by-passed and development partners work directly withsector units at each administrative level to expend and account for funds. There are variations
on this channel. Some development partners centralize disbursement responsibility at thefederal level (so that even regional contractors are paid centrally). Other donors have worked
directly with regional and/or Woreda administrations. Channel 3 is whereby development
partners usually carry out any procurement and pay the contractor directly. Government
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merely agrees to, and budgets for, what is to be provided by the donor, and ensures that theexpenditures are included in any overall HSDP accounting and auditing.
In-addition to the above three channels, there are two channels which operate specifically inthe health sector. These are: 1) Technical Assistance Pooled Fund: established in 2005 by fivedevelopment partners to provide support to FMoH this fund fills critical gap in capacity of
government, is the first of its kind as a pooling arrangement in the health sector. It provides
support in technical assistance, sector reviews, operational research, and other activities at
FMOH level. Currently UNICEF manages the fund. 2) The MDG Performance Fund: MDG
Performance Fund started working in 2007 with funds from GAVI for health systems
strengthening. A huge financing gap in health systems, maternal health, and the particularnature of health services – a large number of public good elements in service delivery and ahigh proportion of recurrent inputs bought internationally (medicines, commodities andequipment) – warrants the establishment of a strong FMOH Level MDG Performance Fund tosupport the implementation of HSDP. The MDG Performance Fund will help to finance fourthematic areas: a) Health extension programme, b) Service delivery (MCH), c) Public healthcommodity procurement and d) Health systems strengthening.

3.4.2 Health insurance
In Ethiopia out of pocket payment by households covers 48% of the child health expenditure(FMOH/NHA-5, 2014). Ethiopia adopted two health insurance models: community based healthinsurance (CBHI) for the rural population and informal sector, and social health insurance (SHI)
for the formal sector (including pensioners). In 2010 the SHI Proclamation was approved by theCouncil of Ministers and by the Parliament and in 2011The Ethiopian Health Insurance Agency(EHIA) has been established. Since its establishment EHIA has been working on building its
capacity and leveling the ground to phase in the health insurance scheme.
The CBHI scheme has brought promising results during its pilot phase. In the 13 woredas whereis was piloted the scheme registered 47% of the households (total: 141,656 households,
119,426 paying and 22,230 non-paying) and generated ETB 20,671525.07. Through use of the
CBHI the health service utilization has substantially increased in the pilot woredas reaffirming
the plan to use the scheme along with SHI as vehicle for Ethiopia’s pursuit towards universal
health coverage.

24National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

4: NEWBORN AND CHILD SURVIVAL STRATEGIC FRAMEWORK
4.1 Visionx

By 2035, every child in Ethiopia enjoys the highest attainable standard of health anddevelopment with an end to all preventable child deaths.

4.2 Goalsx

To reduce under-five mortality from 2013 level of 64/1,000 to 29/1,000, infantmortality rate from 44/1000 to 20/1000 and NMR from 28 to 11/1,000 by 2019/20.

4.3 Objectivesxxx

To ensure effective universal coverage of high impact neonatal and child survival
interventions with special focus on the poorest and marginalized sections of the
population including in regions requiring equitable development
To ensure provision of high quality essential health care for mothers, newborns andchildren at the community and health facility levels
Ensure community empowerment and demand creation for effective use ofnewborn and child survival interventions and promote key family and community
care practices

25National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

4.4 Guiding Principles
The following guiding principles are compatible with the common values of the Health Sector
Transformation Plan and the” Promise Renewed Call to Action for Child Survival Roadmap”. The
principles provide guidance for policy decisions, program priority setting, design ofinterventions, approach to implementation; and resource allocation criteria for achievement of
the Strategic Plan.
The key guiding principles include:
x Country ownership, leadership and accountability – The FMOH and RHBs will continue
to own, lead and coordinate the implementation of the national newborn and childhealth strategy.
x Equity and Accessibility - Provision of comprehensive quality universal health services
will be emphasized across income, gender, ethnicity, and geographical regions andlifestyles.
x Community engagement, empowerment and ownership. Communities should
meaningfully participate in planning, implementation, monitoring and evaluation ofinterventions at family, community, and facility level.
x Integration: integration of the interventions across the health service delivery
mechanisms starting from the primary to the tertiary levels as per the standards set foreach delivery mechanism.
x Partnership - National and international partners have been, and continue to be, very
important in the development of child survival and health programs in Ethiopia. The
Health Sector Development Plan encourages participation of the private sector and the
NGO sector by creating an enabling environment for participation, coordination andmobilization of funds.
x Efficient use of resources: the strategy recognizes the importance of resources and itemphasizes the need for efficiency with which resources will be spent.
x Innovation and use of technology: Medical equipment and technologies are vital
components of the health care delivery and a system for maintaining the supply chain
must be in place. In addition, the strategy will employ innovative health care delivery
approaches to ensure access to and quality of newborn and child survival interventions.
x Responsiveness: to changing economic, social, environmental, climate, technical andepidemiological content to provide effective support to ensure adaptability andsustainability.
x Evidence based decision-making - the strategy will promote the performance of basic
and operational research to support the decisions made at all levels with evidence.
x Quality of health care services – the strategy will ensure interventions implemented has
a skill mix of human resources at all levels of the health system to increase bothcoverage and quality.
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National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

5: KEY NEWBORN AND CHILD SURVIVAL INTERVENTIONSThis section defines target conditions to be addressed in the implementation of the national
newborn and child survival strategic plan and highlights priority high impact interventions for
newborn and child survival.

5.1 Target conditions for child survival
The target conditions account for the majority of the under-five mortality in Ethiopia, and are
therefore the focus for interventions in this Strategic Plan. The 2013 global LiST estimates for
Ethiopia showed that neonatal complications (prematurity, asphyxia, neonatal sepsis, neonatal
tetanus, neonatal pneumonia, and other neonatal causes) are the leading causes of under-five
mortality in Ethiopia. Pneumonia and diarrhea remain to be leading causes of death for children
who passed their neonatal period. As shown in Figure 8, pneumonia, diarrhea and the three
newborn conditions account for nearly 90% of childhood lives to be saved during 2015/16 –2019/20 by implementing the package of newborn and child survival interventions.
Figure 8: Proportions of lives saved by addressing leading target conditions, 2015-2020

However, the estimation showed that meningitis, malaria, measles and HIV/AIDS play arelatively minor role. The LiST model also estimated that optimal implementation of the27National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

package of key interventions will prevent a total of 415,688 and 210,234 under-five andneonatal deaths, respectively, over the period of five years. The five most effective
interventions are: institutional delivery, oral rehydration solutions (ORS), case management ofpneumonia, breastfeeding and case management of severe neonatal infections. Overall,
implementing the revised package of high impact interventions is expected to reduce theunder-five mortality to 29/1,000 live births by 2020.

28

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

2020

415,688

Table 1: Additional deaths prevented in children under-five years of age relative to impact year2019
110,060

210,234

12,291

34,29027,987

15,73343,721

33,48919,07452,562

38,52427,894

66,41843,37732,34975,72748,36636,90285,26853,363

41,485

94,84858,33946,079104,418

63,27750,669113,946

145,518

84,449229,967

2015-20202018
98,02758,600205,454

21,721

21,9992025

201784,25352,02451,460

6,281

2024

2016
59,63544,63246,002

11,255

15,4402023

43,05427,43739,621

3,176

2022

20,65919,63732,198

8,079

2021

7,904
23,4182015
Total (0-60months)<1 month
12,755

Optimal case scenario

1-59 months
Total (0-60months)<1 month

Medium case scenario

1-59 months
Total (0-60months)<1 month
247

29

276

358

54

412

271

77

348

168

99

268

113

122

235

78

143

221

56

149

205

43

153

196

34

157

192

23

161

184

13

165

179

1,235

524

1,760

Base projection - No coverage change

1-59 months

29

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

5.2 Priority High Impact Interventions for newborn and child survival
The selection of interventions as key high impact intervention builds on previous achievements
and it is based on current evidences on the feasibility and effectiveness of implementing theidentified interventions. The selection of preventive and promotive approaches is based on
reduction of exposure to infection and the likelihood that exposure leads to disease. Clinicalcare is added to reduce the likelihood that the disease or condition will lead to death.
The strategy encompasses almost all of the high impact interventions listed in the 2005 national
strategy plus other high impact cost effective interventions and delivery mechanisms whichwere either already introduced or in the process of being introduced in the Ethiopian healthsystem (Table 2). Preparations are being finalized to introduce three new high impact neonatal
interventions, namely; community case management of neonatal sepsis, chlorhexidane cordcare at birth both at community and facility levels and provision of antenatal corticosteroids at
hospital level to prevent deaths among preterm births.
New vaccination programs that are on pipeline for introduction in Ethiopia in the next couple ofyears include birth dose HepB, two doses of Intradermal Poliomyelitis Vaccine (IPV), inclusion of
Meningitis A vaccine in routine vaccination schedule, Human Papilloma Virus (HPV) vaccines for
9 – 13 years old children, and combined Measles vaccine (Measles with Rubella).
Table 3 shows the full package of the interventions to be implemented till 2020 and beyond
including the baseline coverage and targets for 2020. The data source for 2014 baseline wastaken from 2013/14 HMIS and from the different community/facility based surveys. Effort wasmade to identify up to date population based data for each interventions. However, in cases
where such data could not be found estimates of the 2014 baseline coverage were made byexpert groups based on available data from previous period or based on facility-based
estimates.

30

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Expected impact
Prevention of 5 diseases including pneumonia due to Hib
Increasing birth spacing to improve birth weight and survival ofchildrenCommunity based pneumonia case management is estimated toresult in a 20% reduction in all cause of under one mortality & a
24% reduction in all causes of under-five mortality.
Believed to significantly improve access to the treatment of
uncomplicated severe acute malnutrition at community level.

A PCV conjugate vaccine is expected to prevent about 26% ofradiologically confirmed pneumonia (a severe morbidity proxy formortality).
Improving management of newborn asphyxia
Improved management of PIH and reduced risk of preterm

2013

2013

2011
2013

2010
2010

2011

2008

2010

Year ofimplementation
2007
2008

Table 2: Child survival interventions adopted/on process of adoption after the launch of the 2005 national child survival strategy

Helping babies breath
MgSO4 for management
pregnancy induced hypertensions
Zinc for management of diarrhea
Rota virus vaccine

Community case management of
uncomplicated Severe Acute
Malnutrition
Pneumococcal Vaccine

SN Intervention or delivery
mechanism
1. Pentavalent vaccine
2. Long term family planning by
HEWs
3. Community case management ofPneumonia
4.

5.

6.
7.
8.
9.
10. Option B+ for PMTCT

11. Community case management of
neonatal sepsis

Improve treatment outcome of diarrhea diseases
Effectiveness against the fraction of diarrhea deaths attributable torotavirus is estimated to be 74% (95% CI: 35–90%).
Believed to significantly increase the numbers of pregnant womenbeing enrolled on ARTand increase the likelihood that infants born
to HIV-positive mothers will be born HIV-negative.
Community-based packages with management of neonatal sepsis
by health extension workers achieved large reductions in NMR of
34% to 62% in research studies in India and Bangladesh.
31

Prevents infection by Meningitis A

Cleansing a newborn’s umbilical cord with chlorhexidane canreduce an infant’s risk of infection of the cord by 68% and death
during the first weeks of life by 23%
Provision of antenatal steroids decreases neonatal mortality among
preterm infants (<36 weeks gestation) by 31%.
Prevents Hepatitis B infection
Prevents infection by Poliomyelitis

To be introduced

To be introduced

To be introduced
To be introduced

2014

Prevents infection by Human Papilloma Virus and Cervical Ca

To be introduced

2014

Prevents infection by Measles and Rubella

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

12. Chlorhexidine for cord care

13. Antenatal Corticosteroids forpreterm labor
14. Birth dose HepB
15. IPV (Intradermal Poliomyelitis
Vaccine 2 doses)
16. Meningitis A – will be included in
the routine vaccination schedule
17. HPV (human papilloma virus) –will be provided for 9 -13 year old
girls
18. Combined measles vaccine –Measles with Rubella

32

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

S.N.

Key intervention

1. Family Planning (CPR)*
2. Focused ANC (4/more visits)*
3. Iron Folate Supplementation*
4. ART for HIV+ pregnant women*
5. Tetanus Toxoid immunization (PAB)
6. ITNs for pregnant women (malarious
areas)*
7. Antenatal Corticosteroids forpreterm labor*
8. Mg So4 during pregnancy & atBirth*
9. Skilled attendance at birth*
10. Neonatal resuscitation

Delivery Level

All levels
All levels
All levels
Clinical CareAll levels
All levels
Clinical care
(Hospital)
Clinical care
Clinical careCommunity care
Clinical careCommunity care
Clinical care
All levels

Community care
Clinical care
Clinical care

Baselinecoverage(2013/14)
42%
32 %
34 %
61%
68%
35%

90%

55%
95%
95%
95 %
90%
80%

UNICEF 2012

Source of current
baseline data

No data

90%

Mini EDHS 20142020
target

1%

95 %
90%

Mini EDHS (Assisted byskilled attendant andHEW)Mini EDHS 2014
Mini EDHS 2014
Mini EDHS 2014
HMIS 2006 EFY
EPI Cluster Survey 2012
MIS 2011

15 %No data

90%

90

0%

10

90%

95%

No data25%

Table 3: Package of high impact Child survival interventions along continuum of care, current coverage & 2020 targets
Continuum ofCare level
Pre-pregnancy
Pregnancy

Birth andpostnatal

11. Chlorhexidine for cord care
12. Thermal regulation

13. KMC
14. Antibiotics for Premature Rupture of
Membranes (PROM)*

33

S.N.

Key intervention

15. Postnatal visit for mothers andnewborns within 48 hours*
16. Antibiotics for neonatal sepsis
17. Early initiation of breastfeeding(within 1 hour of birth)
18. Exclusive breastfeeding (up to 6
months)19. Complementary feeding (age 6-9months) and continued breast
feeding
20. Penta_3 (DPT-HepB-Hib) vaccination
21. Pneumococcal vaccine
22. Rota Virus vaccine
23. Measles immunization
24. Vitamin A supplementation every 6month*
25. Antibiotics for pneumonia

52 %No data
51%

Baselinecoverage(2013/14)
12%

100%

80%

80%
90%

50%

EDHS 2011

EDHS 2011

EDHS 2011

Mini EDHS 2014

Delivery Level

All levels

50 %

96 %

Source of current
baseline data

All levels

66%

2020
targetAll levels

Community care
Clinical care
All levels
All levels

All levels
All levels

80 %Malaria indicatorsurvey 2011
EDHS 2011

EDHS 2011
EDHS 2011

96%
96%
96 %

7%

90%

80%
42%
68%
All levels

31%

100 %

95%

33%

80%

88%
All levels
All levels
All levels
All levels
Clinical care

14.4%

EPI Coverage survey
2012
HMIS EFY 2006
HMIS EFY 2006
EPI Coverage Survey
2012
Post EOS/CHD
validation survey

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Continuum ofCare level

InfancyChildhood

26. Oral Rehydration Therapy (ORS) andZinc
27. Malaria ACT treatment
28. Antibiotics for dysentery

34

S.N.

Key intervention

All levels
All levels

Clinical careCommunity care
Outreach service
All levels
All levels

Delivery Level

National Strategy for Newborn and Child Survival in Ethiopia, 2015/16 – 2029/20

Continuum ofCare level
29. Pediatric ART*
30. Children sleeping under insecticidetreated nets (ITNs)*
31. Management of children with SAM*
32. Improved drinking water(household)*
33. Improved sanitation facilities(household)*
34. Deworming

70%
55%

Baselinecoverage(2013/14)
9.5%
38%

100%

90%
100 %

80%
80%

HMIS 2005

WASH Inventory 2012

National HAPCO 2014
Malaria indicatorsurvey 2011
Program report
WASH Inventory2012

Source of current
baseline data

63 %

90%

2020
target88%* All these interventions are cost effective evidence based interventions that are known to have high impact on newborn and child mortality. The costingfor these interventions is not included in this Newborn and Child Survival Strategy. The cost of these interventions is addressed by specific programs(maternal, nutirition and other strategies) and by the HSTP where all programs align to the national plan and targets.
35

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

6: SERVICE DELIVERY LEVELS AND STRATEGIESOne of the most important steps to improving child survival is the adoption of a comprehensive
approach to service delivery. The continuum of care approach as a service delivery model iscomprehensive on many fronts. The central premise of the model is the delivery of essential
services for mothers, newborns and children in an integrated package at critical points in thelife cycle, in a dynamic health system. The continuum of care has two dimensions: time of caregiving and place and approach of care giving.
In time - an effective continuum of care connects essential maternal, newborn and child healthpackages throughout adolescence, pregnancy, childbirth, postnatal and newborn periods andinto childhood building upon their natural interactions throughout life. Through ensuringlinkage across maternal, newborn and child health service delivery points within health facilities
it will be possible to avoid missed opportunities and provide comprehensive service fornewborns and children at community and facility levels.
In place - an effective continuum of care strengthens the links between the home and the firstlevel facility and hospital assuring the appropriate care is available in each place (Figure 9).
Strategies involve improving the skills of health workers, strengthening health system supports,
and improving household and community practices and community actions for health. Thisapproach brings care closer to the home through outreach services and promotes referral bystrengthening access to and improving the quality of services at peripheral and district level
facilities.
Figure 9: Continuum of care approach: time of care giving and place and approach ofcare giving
Pregnancy

Postnatal(mother)

BirthMaternal Health

Postnatal(newborn)Communities

Households

36

Infancy

Linkage and referral

Health Facilities – Primary andreferral care
Outreach

Adolescents &Pre-pregnancy

Childhood

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

The service delivery strategy is presented in line with the three key objectives and based on theimplementation of high impact interventions at each service delivery level starting from thehousehold/community up to the referral or specialized care facilities.
Community based interventions: Ethiopia has demonstrated that basic health services can bemade accessible to large proportion of the population through the government-led costeffective community based health delivery platform. Building on the government flagshiphealth extension program at the community level priority will be given to scale up ofcommunity based newborn and child survival interventions through HEWs and HDAs. The main
objective is to achieve universal coverage with community-based promotive, preventive andcurative interventions and strengthen the capacity of HEWs and HDA networks.
Population oriented outreach services: In a country like Ethiopia, where geographical accesspresents major barriers, population oriented outreach preventive-promotive interventions
provide an avenue for community action, expanded access and coverage for preventive,
promotive and basic curative services; and creates the required linkages between community
services and health facilities. The newborn and child survival strategy will provide populationoriented scheduled services by health workers with basic skills during regular outreach services,child health days and campaigns. This may be delivered through routine and scheduled
outreach or mobile health care in a health facility in a scheduled manner. When schedulingoutreach and mobile health services attention will be paid to variations in access to services
within the community. Focus will be on areas or populations that are underserved. Outreachand mobile health services will be planned with the community and community members will
provide support to services such as tracking defaulters. Evidences show that increased coverageof outreach and facility-based preventive interventions will reduce neonatal mortality by 3.5
percent, under-five mortality rate by 3.3 percent in countries with similar setting(Malawi/MOH, 2008).
Individual oriented clinical services: This service-delivery mode requires effective functionaland referral coordination among the health service extension workers and health workers withadvanced skills (nurses, midwives, health officers and physicians trained in emergency
obstetric, newborn and child health care). Services should be available on a permanent basis.
The individual oriented clinical services addresses individual specific clinical services required bynewborns, children or pregnant women who are sick or giving birth. Although preventive andpromotive services are important in reducing under-five morbidity and mortality ending
preventable newborn and child deaths requires back-up facility-based high quality services forreferral care for sick children, pregnant women presenting with complications, and womenrequiring emergency obstetric care to the very minimum. Once key bottlenecks are addressed,
the individual-oriented clinical services can lead to 25.8% decrease in neonatal mortality rateand 23.6% reduction in under-five mortality (Malawi/MOH, 2008).

37

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

Infrastructure development will be required to strengthen this strategy. Accelerated expansion
and staffing of primary health care facilities with strong two-way referral system along withstrengthening the secondary and teritiary care facilities, and training of health workers isneeded to achieve universal coverage. Accelerated in-service training of medical andparamedical staff on key MNCH interventions is essential to fill the skill gaps. However, follow
up after training and supportive supervision remain the key actions to reinforce skills andfacilitate implementation. To ensure sustainability of having health staff adequately skilled in
MNCH services, the pre-service education programs should be strengthened and incorporate
new knowledge on high impact MNCH interventions.
Quality of newborn and child care: Improving quality of newborn and child health care is apriority cross cutting issue that FMOH will invest on in the next years. To this effect FMOH will
strengthen its work to improve the quality of newborn and child health services provided at thethree levels dicussed above. The strategic initiatives on quality of care including improvementin the emergency management system, regulation of non-public providers, blood transfusion
provision, medical care SOPs and monitoring, integration of service provision, and functionalreferral services will be fully implemented. In addition, all hospitals will be made to fully
implement standards in the Ethiopian Hospital Reform Implementation Guideline (EHRIG).
Innovative quality improvement approaches will be tested, documented and scaled up.
In the next pages the strategy outlines key interventions and initiatives across the threeobjectives that will be implemented at the three levels of care discussed above. Some of theinterventions may contribute to achievement of more than two or all the three objectives but
are presented under the objective to which they will contribute more.

38

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

6.1 Objective 1: Ensure effective universal coverage of high impact neonatal andchild survival interventions with special focus on the poorest and marginalized
sections of the population and regions that require equitable development
6.1.1 Community Based Interventions
Essential medicines, commodities and logistics
•
•
•

•

Improve system for procurement of essential medicines and commodities.
Strengthen integrated pharmaceutical logistic system at the PHCU and drug supply andmanagement system at community level
Ensure all health posts have means of transport (bicycle) or equivalent and basic kit forcommunity health work, including medicine kit, information, education andcommunication (IEC) materials, boots, uniform and identification tag.
Promot local production of commodities (chlorhexidine, zinc/ORS etc)

Capacity of HEWs••

Deploy appropriate number of HEWs to ensure the health posts are adequately staffed
for provision of health services at all time at home, within sub-village and at the healthposts.
Train HEWs on basic preventive and curative services such as essential newborn care,
iCCM, CBNC, CMAM, maternal health, clean delivery, KMC in case of emergencies etc.

Provide counseling and care at home and health postsxx
xx

Conduct regular mapping of households with pregnant women, newborns and underfive children
Conduct planned monthly household visits to provide individual counseling on highimpact maternal-newborn health and child survival interventions and provide care asneededRegularly follow up with case-specific households to monitor family compliance withpregnancy monitoring and monitoring of child growth and development in the areas of:nutrition, breastfeeding, immunization schedules, vitamin A, treatment advice, etc.
Provide targeted basic health promotive, disease preventive and curative services athome and in the health posts

Monitoring, supervision and reporting••

Improve the use of the family folder and community health information system tomonitor the uptake of high impact interventions.
Conduct monthly reporting and supervision meetings between each extension worker,
and the health center staff of the catchment area to ensure data use for decision
making39

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

•
•

•

•

Strengthen the primary health care unit to facilitate supportive supervision and referral
linkage
Establish system for use of data in the bimonthly meetings of HEWs with healthdevelopment team leaders to review their progress and improve the service delivery formothers, newborns and children.
Work in collaboration with other community structures such as the agriculture
extension workers to increase coverage of high impact MNCH interventions and birth
registration through coordinated effort.
Strengthen the mhealth for Ethiopia’s large rural based communities to accelerate
public health intervention through real time data exchange, referral linkage,strengthening supply chain and disseminating important information.

6.1.2 Population Oriented Outreach Services
Essential medicines, commodities and logistics•••

Establish supply and inventory management system for essential products at health
posts
Build capacity of staff on supply chain fundamentals and provide basic skills trainings
Ensure availability of vehicles and motorbikes with fuel for integrated outreach andreferral services

Capacity of Health workers and HEWs•

Train additional health workers and extension workers for integrated outreach services(EPI, growth monitoring, ITNs, ANC, iron-folate, vitamin A, de-worming, family planning,
HTC, etc);

Provision of outreach counseling and care•••

Integrate service provision of: CBNC, EPI, growth monitoring, ITNs, ANC, iron-folate,vitamin A, de-worming, family planning, HTC, etc;
Conduct regular, defined and predictable scheduled outreach from the HP/ HC to eachidentified community site
Enhance supportive supervision at all levels.

Monitoring and supervision•

Strengthen monitoring system for all high impact interventions provided at outreachand static service delivery points (HMIS) and conduct periodic population-based
Surveys..

6.1.3 Individual Oriented Clinical Services

40

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

Essential medicines, commodities and logistics•••

Ensure availability of tools and forms required for Integrated pharmaceutical logistics
system (IPLS) for HPs
Procure and install essential diagnostic and other equipment required for out-patientand in-patient MNCH care;
Ensure availability of medicine, commodities and logistics to strengthen the care fornewborns with especial attention to premature and low birth weight babies in the NICU

Capacity of Health workers
•

•
•

•
•
•

•

Fully operationalize Human Resources for Health Development Plan prioritizing
underserved areas for delivery of high impact interventions for maternal, newborn andchild care;
Recruit/deploy adequate staffing for each level of care as per FMoH staffing norm;
Train at least 2 staff per health facility in skills for delivery, essential newborn care,newborn sepsis management, lifesaving skills, and emergency obstetrics care, including
management of 3rd stage of labour during deliveries;
Train at least 2 staff per health facility in skills for IMNCI and other child healthinitiatives
Train nurses at least 4 to 6 nurses per hospital to care for newborns in the NICU wards
Train medical and paramedical university faculties as trainers of trainers in reproductive,
maternal, newborn and child health and nutrition care, including IMNCI and iCCM inorder to roll out in-service and pre-service training;
Integrate training in newborn and IMNCI, pediatric AIDS care, and emergency obstetrics
care in pre-service training curriculum of all medical and paramedical training
institutions;

Infrastructure
•

•
•
•

Construct additional primary healthcare facilities to achieve minimum standard norm
per defined population (e.g. 1 health centre for with BEmONC service for 25,000
population; and 1 hospital with C-EmONC services for 100,000 population);
Renovate/refurbish primary hospitals to provide quality MNCH services
Ensure that each primary hospital avails space for a level I NICU and the secondary andgeneral hospitals for level II and above NICUs
Ensure availability of reliable water, sanitary, communication, ambulance and power
supply in health facilities with backup plan for power outages

Provision of individual oriented clinical care••

Provide 24 hour integrated maternal, newborn and child health services in healthfacilities particularly for skilled delivery, EmONC and pediatric emergency care;
Ensure there is a functional newborn corner in each of the health centers, and newborn
ICUs in hospitals to take care of high risk and sick neonates
41

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020•

Ensure that blood transfusion services are available at C-EmONC facility

Monitoring and evaluation••

Conduct maternal, newborn and child death surviellance and response system in healthfacilities and clinical audit
Provide regular integrated supportive supervision to enhance quality of care

42

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

6.2. Objective 2: Ensure provision of high quality essential health care forwomen and children at the community and health facility levels
The provision of high quality essential health care for women and children needs a continues
effert to improve process, output and outcome by addressing the challenges and bottlenecks
across the components of the health system. The strategy for quality health care provision willbe the main guide and some of the activities are listed below.

6.2.1 Community Based Interventions
The key strategies to scale up quality high impact interventions provided through communitybased services are:

Availing essential medicines, commodities and logistics••

Strengthen PHCU to ensure uninterrupted availability of essential medicines,
commodities and supplies
Establish and regularly restock the medicine kit with defined list of essential medicines,
consumables and basic supplies (anti-malarials, amoxicillin dispersible tablets,
paracetamol, oral rehydration salts (ORS), de-worming tablets, Ready to Use
Therapeutic Food (RUTF), amoxicillin etc.) for all health posts

Capacity building for HEWs•••

Equip HEWs with communication and counseling skills
Strengthen the skills of HEWs on assessment and management of newborn and childhealth problems at community level (including ICCM, CBNC, CBN, EPI, TB/HIV) andprompt referral to the next level.
Provide refresher and further training of HEW to ensure delivery of quality basic healthpromotive, disease preventive and selected curative services

Community empowerment and demand creation••

Institutionalize home visits by HEWs to all households within catchment
kebele/population, including more frequent visits to households with high-risk families.
Develop tools and checklists that HEWs can use to review performance of 1-to-5 HDA
network and team leaders during their regular meetings

Provision of basic family-level counseling and curative services•

Build capacities of HEWs and caregivers to prevent, manage and provide basic care forcommon causes of childhood illnesses at home, such as treatment of malaria,
pneumonia, diarrhea, neonatal sepsis, uncomplicated acute malnutrition and deworming of children, etc.
43National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020••

Ensure health posts provide women and adolescent friendly services in a manner thatguarantees confidentiality and privacy
Strengthen linkages and two way referral between health facilities and healthposts/communities

6.2.2 Population Oriented Outreach Services
Essential medicines, commodities and logistics•••

Review procurement procedures for vaccines and injection materials
Strengthening integrated pharmaceutical logistic system at the PHCU
Improve maintenance system of cold chain, transport means and other equipment.

Capacity of Health workers and HEWs•

Ensure outreach services are women friendly services, address concerns of women andfamilies and guarantees confidentiality and privacy

Provision of outreach counseling and care•••

Conduct community-level micro-planning of integrated outreach services, identifying
and mapping under-served communities and developing schedules to extend outreachservices to themStrengthen referral system and continuum of care in outreach programs
Ensure outreach programs are designed to extend mentorship and supportive
supervision to lower level facilities

Monitoring and supervision•

Strengthen monitoring system for all high impact interventions provided at outreachand static service delivery points (HMIS).

6.2.3 Individual Oriented Clinical Services
Essential medicines, commodities and logistics•••

Improve supply chain and delivery management for essential drugs and supplies ofhealth facilities with no stock-out of any single newborn and child survival supply formore than 2 weeks;
Equip BEmONC centers with essential equipment and supplies including equipment andsupplies for neonatal care;
Support establishment of transport and communication systems (ambulances and otherlocal transportation systems) for referral between rural areas and nearby healthfacilities.

44National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

Capacity of Health workers••

Institutionalize motivation and retention mechanism for health workers at health facility
levelWork with health professional associations; to implement continuous professional
development of health workers, improve quality of pre-service and in-service training ofhealth workers

Provision of individual oriented clinical care••

Improve transport system for emergency referrals of obstetrics and pediatric cases
between community level/health center and hospitals; andIntroduce MNCH quality standards and continuous assessment of the performances ofthe standards to improve quality of care in service provision in all health facilities.

45

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

6.3 Objective 3: Ensure community empowerment and demand creation for
effective use of newborn and child survival interventions and promote key
family and community care practices
6.3.1 Community Based Interventions
Community empowerment and Demand Creation
•

•
•

•
•

•
•

•
•
•

•
•

•

Update and/or develop IEC/BCC materials and related tools to promote use of highimpact MNCH services as per the national health communication material development
and implementation guidelines.
Conduct regular household visits to provide individual counseling on high impact
reproductive/maternal-newborn and child survival interventions and care as needed
Strengthen the 1-to-5 HDA network by training network leaders on key MNCH
behaviors and practices for awareness creation to support issues related to maternalnewborn and child survival.
Conduct regular mass media activities preferably radio programme to support maternal,
newborn and child survival initiatives.
Build capacity of Media such as health sector program columnists, producers/directors,
editors and journalists of both print and electronic media at national/regional levels on
newborn and child survival issues.
Promote uptake of high impact newborn and child survival interventions to ensure
Home Delivery Free (HDF) communities and Community Led Total Sanitation (CLTS)
Use religious leaders, and social gatherings (like Gedda and irecha, in Oroma Culture) toshow /discuss various newborn and child survival issues with caregivers and at thehealth facilities during waiting time, including videos, audios and printed tools.
Use traditional communication strategies such as the ‘Dagu’ in the Afar region.
Document, disseminate and scale up newborn and child health best practices
Conduct national level mega events involving celebrities etc – Awarding for good
performance and contribution (Health workers, administrative and political leaders, key
civil society organizations
Fully engage leaders and groups at different levels and capacities, including
parliamentarians, in promotion of newborn and child survival interventions
Use mHealth platform – Mobile based collection and delivery of MNCH information tomothers, families and health workers, for referral and linkage, for tracking, for datacollection and reporting, and track of stock levels and reporting of stock outs of supplies
Create consultation/mentoring platform by linking HEW and HDA with newborn andchild health specialists at different levels through use of mobile applications

46

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

6.3.2 Population Oriented Outreach Services
Community mobilization for services uptake••

Social mobilization for improved uptake of preventive services, including male
involvement and defaulter tracking for immunization, ANC, HTC, FP, etc;
Utilize the HDA and 1-to-5 network to identify families who need services that can beprovided through community scheduled outreaches, and trace defaulters.

6.3.3 Individual Oriented Clinical ServicesxxTrain health workers on Interpersonal Communication skills and key approaches andcommunication skills as per FMOH standard training guidelines, manuals and tools.
Support innovative social marketing of newborn and child survival interventions
using private sector partnership.

47

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

6.4 Supporting Strategies
The following strategies aim to strengthen the health systems and support the child survival
strategy through logistics management; resource mobilization and management; and humanresources for health.

6.4.1 Resource mobilization
One of the main constraints to a scaled-up and accelerated implementation of newborn andchild survival interventions is inadequate financial resource. There is also concern over thepredictability and sustainability of funding from development partners. Therefore; there is aneed for mobilization and commitment of significant and sustained financial resources in orderto achieve the targets set in this strategic plan.
The major actions are:• Share some of the priority investments from HC/HP to Primary Hospitals to ensure
continuity of care and expand the availability of CEmONC and quality referral care fornewborns & children.
• All woredas must a have budget for emergency prepardness and response• Prepare a budgeted plan to provide guidance for financial requirements andimplementation of the strategy and continue advancing the One Plan and One Budget
approach at all sector ministries, regional health bureaus and woreda health offices• Mobilise additional funding for EPI, IMNCI, especially for ICCM & CBNC
• Develop program/project proposals to mobilize additional resources from development
partners, private sectors, foundations and other sources for the implementation of thestrategy

6.4.2 Human Resources for Health
The strategy depends on both short and long-term recruitment and training of skilled staff tomeet the maternal, neonatal and child health care service needs of the country. All MNCH
trainings must adhere to quality standards. Training institutions will have their representative
included in the child survival technical committee at each appropriate level to ensure that theywork within the framework of the National Newborn & Child Survival Strategic Plan. The
partnership with the Ministry of Education and health training institutions needs to continue
strengthened to ensure the comprehensiveness and quality of the pre-service education in
MNCH.

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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

As indicated in the national human resource strategy the pre-service medical education shalladdress the emerging shift in disease and disability burdens and service expansion with thecontext of sub-specialization. Medical and other training institutions shall thrive to produce
sub-specialty taskforce in pediatrics, perinatal medicine, surgery, nursing, growth anddevelopment, dietetics and nutrition so that the problems of pediatrics disease conditions,neonatal conditions, congenital anomalies, perinatal conditions, surgical conditions, injuries,
growth and development and behavioral conditions are addressed.
There is also a need for Continuous Professional Development (CPD) of MNCH providers. Rapidroll out of Continuuing Professional Development and in-service training schemes will require
forming a team of TOTs to cover a given region/woreda where they can plan and execute
training courses for all key cadres within the region/woreda.
The major actions are:
• Expand capacity building and career structure for both rural and urban HEW• Strengthen mechanisms to develop and retain high quality health care professionals(licensure, accreditation, and board certification), as rapid expansion of human resourcefor health strategy continues• Support growth , development, and transformation along defined career paths• Strengthen mechanisms for sustained human resource utilization, retention andperformance• Strengthen coordinated partnership with the MoE, partners and the private sector forrobust human resource development• Develop institutional capacity in MOH, Regional Health Bureaus, and related agencies tobe responsive to changing economic, social, environmental, technical, andepidemiologic context• Strengthen the Human Resources Information System (HRIS) for accurate planning

6.4.3 Logistics Management
Gap in logistics management is one of the constraints identified as bottleneck in theimplementation of newborn and child survival programs because of delays, failure to supply
vaccines, drugs, mosquito nets, etc. The various programs involved in maternal, neonatal andchild health will have to undertake thorough quantification of their logistical needs and develop
a robust procurement plan that takes into consideration lead time from order to delivery andthe need for sufficient buffer stock. These should be done within the institutional framework
and with institutional support from central logistics management unit. Quantification should
also consider the logistical needs of community-level services.
Each intervention unit will ensure that woreda-level essential drug and supplies quantificationand forecasting includes requirements for clinic days and home visits by HEWs and for
emergency treatment. Equitable access by all woredas must be ensured. At community level,49

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

the drugs kit of the HEW should be regularly restocked, taking into account the amount of drug
issued, the amount used and the number of patients treated.
The main objective is to:• Strengthened capacity for logistics management including adequate functioning of cold
chain, supply of medical equipment, availability of transport for referral and supervisionat all levels of health systems.
• Ensure availability of adequate supply commodities, supplies and drugs at all levels of
healthcare delivery system.
The major actions are:• Facilitate quantification, procurement and distribution of drugs, supplies andcommodities and maintain sufficient levels of stock at all times;• Monitor utilization and ordering of drugs at all levels of service provision;• Orientate pharmacy technicians and health centers on logistics management• Procure additional transportation and communication equipment and supplies.
• Local production of essential MNCH commodities• Ensuring accountability for availing the essential commodities for women’s andchildren’s health as per the UN Commission requirements

6.5 Implementation of the Strategy
The strategy is contingent on the implementation of the Health Sector Transformation Plan
(HSTP) and the overall National GTP II implementation plan. The strategy aims to ensure
universal effective coverage of quality newborn and child health interventions through closing
the existing gaps in realizing equitable access and use of services across regions and among
different sections of communities.
Granted that things will progress according to the plan, by 2020, 100% of the population will
have access to essential newborn and child health care with high quality essential health service
and the population will be empowered to use the services availed. The strategy proposes closemonitoring of the implementation of its interventions and their impact with frequent reviews ofprogress. This dynamic approach will permit timely corrective measures to be taken at local or
national level as soon as they are needed. It will also allow for the introduction of new
interventions as soon as practical procedures and innovatons are made readily available.

6.5.1 Health care for the newborns and children in regions requiring equitabledevelopment and special population segments, including pastoralist and cross-bordermobile communities

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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

The context specific needs of communities in regions requiring equitable development andpastoralists areas make a one-size-fit-all approach challenging. The FMOH, with input fromhealth development partners with suitable experiences and in collaboration with all concerned
sectors, will support the development of relevant context specific service delivery strategies toreach communities in regions requiring equitable development with preventive, promotive andcurative newborn and child health interventions at all levels of the health delivery system.

6.5.2 Public Private Partnership for implementation of the Newborn and Child Survival
Strategy
The partnership between public and private sector should be strengthened, in line with the
HSTP approach, through collaboration with the private sector on the expansion of healthinfrastructure, local production of pharmaceuticals, provision of health services, training ofhealth professionals and mobilization of resources for the health sector and by collaboratingwith professional associations in reducing professional malpractices towards improving qualityof health services for newborn and child survival.

6.5.3 Intersectoral and MultiSectoral Colaboration for implementation of the
Newborn and Child Survival Strategy
Inter-sectoral collaborations should be practiced at different levels of the health systemthrough the formal government institutions (such as regional and woreda councils) and healthsector governance structures (such as CJSC, RJSC and WJSC) by practicing initiation of joint
planning, implementation, monitoring and evaluation at all levels of the health system as it has
been elaborated in various documents of MoH. Since health is an integral part of sustainablesocio-economic development efforts, there should be a collaborative activitiy between
different ministries, institutions, organizations and the MoH for the implementation newborn
and child survival strategy.

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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

7: PARTNERSHIPS, ROLES & RESPONSIBILITIESA sustainable and long-term reduction in child mortality depends on complementary actions at
different levels and by all key sectors. The health sector can produce rapid changes in childhood
morbidity and mortality by addressing specific causes of illnesses and death. However, thehealth sector is not in a position to address underlying determinants of maternal and childhood
mortality, such as: lack of education; low status of women in society; availability of transportand good road networks for referrals; adequate supply of food, safe drinking water, and power
etc. Active cooperation and participation of other sectors is therefore needed to address theseunderlying determinants of child survival and development.

7.1 Partnerships for the Newborn and Child Survival in Ethiopia
Several local and international partners support the planning, implementation, monitoring andevaluation of maternal, newborn, child and adolescent health interventions in Ethiopia. Someof these partners include:1. UN agencies
2. Bilateral and Multi-lateral organizations
3. Local and internation MNCH implementing partenrs.
4. Universities – particularly medical & health professional training institutions
5. Professional societies – Ethiopian Pediatric Society (EPS) , Ethiopian Society of Obstetrics
and Gynecology (ESOG), Ethiopian Public Health Association (EPHA), Ethiopian Nursemidwives Association (ENMWA), Ethiopian Nurse Association (ENA), Ethiopian
Pharmacists Association (EPA), Public Health Officers Association (PHOA), Ethiopian
Medical Association (EMA), etc
6. Private sectors – pharmacies, private clinics, private Hospitals, individuals
Implementation of the strategy requires active involvement (partnership) of local andinternational partners, including private sector and NGOs, through participation, coordinationand mobilization of resources. This calls for advancing the one plan, one budget and one reportapproach. Partners are expected to advocate for equitable access for evidence-based MNCH
interventions, provide financial and technical support including monitoring and evaluation of
implementation of high impact MNCH interventions.
The major actions of the national partnership are to:• Hold major stakeholder meetings to harmonize operation and arrive at a common
understanding on selected issues, including: (a) targets year by year; (b) time of key
activities; and (c) allocation of resources, taking into consideration the funding gaps andintervention coverage levels;• Develop and harmonize a coordinated framework for community and facility levelapproach to child survival and development• Develop a common system for supervision, monitoring and reporting52

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

•
•
•
•

Form Technical Working Groups and Task Forces amongst partners as and whennecessary to achieve a given task;
Conduct bi-annual, quarterly and monthly Joint Program Reviews together with partners
Ensure multisectoral coordination at Federal level
Functionalize the coordinating committees in the Regional States

7.2 Roles and Responsibilities
Federal Ministry of Health
The FMOH takes the lead to:x Provide policy guidance and institutionalization of high impact newborn & child survival
interventions in the national health sector strategic and operational plansx Advocate and mobilize more resources for improving maternal newborn & child survival
x Ensure universal coverage of key interventions with focus on equity and quality ofservices
x Overall coordination, planning, implementation, and monitoring & evaluation of MNCH
services
x Improve health information system and local use of data for decision making
x Develop and update appropriate national guidelines and training packages on MNCH
x Build the managerial and clinical skills of program managers and providers to improve
the quality of MNCH services
x Support the quality of health service graduates through institutionalization of key MNCH
packages in the pre-service education curricula
x Support operational researches and periodic surveys on MNCH interventions
x Ensure all essential MNCH commodities are available in all health facilities & healthposts
x Improve the quality of MNCH services at all levels of the health care system
x Support and monitor the coordination and implementation of child survival programs at
sub-national levels
x Monitor and evaluate the progress of implementation of the national strategy

National Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH)
and Nutrition Technical Working group
The national Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition
Technical Working Group will be chaired by the MCH and Nutrition directorate of FMOH. It will
have the authority on policy and strategic matters and ensures ensure that all the programs at
the national level, including the NGOs and partner projects supporting them abide by one planfor the implementation national HSTP strategy.
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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

The key roles of the RMNCAH and Nutrition Technical Working Group will include
x Co-ordinate the planning of all programs – partners and national to be in line with the
HSTP IIx Advocate for the adoption of RMNCAH and nutrition friendly policies and evidence
based interventions
x Mobilize resources for RMNCAH and Nutrition interventions
x Support each sub technical working groups
x Monitor and evaluate the national implementation of the HSTP II

National Newborn and Child Survival Sub-Technical Working GroupThe national Newborn and Child Survival Technical Working Group is chaired by the Child
Health Team Leader of FMOH. It will have the authority to ensure that all the programs at thenational level, including the NGOs and partner projects supporting them, develop, promote andabide by one plan for the implementation of the strategy.
The key roles of the national working group include:
x Coordinate the planning and implementation of all programs that relate to newborn &child health, in line with the revised national Child Survival Strategy
x Advocate for adoption of child friendly policies and evidence-based newborn & childsurvival interventions
x Mobilize more resources for newborn & child survival
x Develop, harmonize and disseminate technical and managerial guidelines for all aspectsof newborn & child survival
x Support regional planning for child survival
x Support Regional problem-solving and planning for child survival in special populationgroupsx Monitor and evaluate the national implementation of the Strategy – including periodic
reviews of the implementation of the Strategy

Regional RMNCAH & Nutrition Technical Working GroupThe key roles of the regional working group include:
x Coordinate the planning and implementation of all newborn, child survival and nutritioninterventions in the region in line with the revised National Newborn and Child Survival
Strategy, MNH roadmap and Nutrition Program.
x Coordinate the inputs of partners and NGOs working on child survival & nutrition in the
Regionx Disseminate technical and managerial guidelines on newborn, child survival & nutrition
x Ensure the availability of all essential equipment and supplies to health facilities within
the region
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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

x
x
x
x
x

Make sure and recommend all health facilities are staffed with the required skill mixes
and update their knowledge and skills regularly
Develop approaches to meet the child survival needs of special population groups
Collaborate with the Regional offices for Education, Water and Sanitation, agriculture
and nutrition on activities relevant to Child Survival & nutrition
Support Woreda Health Offices in planning for Child Survival and in reviewing progressand solving problems
Monitor and evaluate the implementation of the child survival and nutrition programs,
including periodic reviews

Woreda RMNCAH & Nutrition Committee
The key roles of the woreda working group include:
x Coordinate the planning, implementation, supervision and support of all child survival &nutrition activities in the Woreda
x Ensure that all newborn, child survival and nutrition interventions are incorporated in
the annual operational plans of the woreda and implemented effectively
x Coordinate the inputs of partners and NGOs in the Woreda in the area of child survivaland nutrition
x Improve care seeking behavior through community dialogue and the Healthdevelopment Army (HDA) networks
x Establish linkage with other sector offices (education, water, sanitation, and agriculture)on activities relevant to Child Survival & nutrition
x Ensure adequate staffing of health facilities with appropriately qualified health workers
x Make sure that health facilities are provided all essential supplies and equipment andneeded health care workers relevant to newborn and child survival
x Monitor and evaluate newborn and child survival& nutrition activities, including periodic
reviews of implementation and problem solving.

Kebelle Health Development TeamThe key roles of the Kebelle health development team in relation to newborn and child survival
activities include:
x Coordinate all MNCH and nutrition activities in the kebelle and ensure implementation
through the 1-to-5 networks
x Identify beneficiaries’ including pregnant mothers and under-five children in thecatchment area
x Plan and monitor the implementation of key child survival and nutrition interventions
aiming universal coverage for all beneficiaries’ in the kebelle
x Increase care seeking and effective utilization of preventive/promotive and basic
curative services provided at the health post level55

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020xxWork with the 1-to-5 networks to improve water & sanitation coverage in the villages
Facilitate referral of delivering mothers & very sick children to next level health facilities

Health Development Army
This is a network of women in which those who have adopted better health behavior throughcompleting the 16 packages of HEP are networked to 5 other women who have not yet
completed the 16 packages so that they can influence the later to practice a healthy life style.
Five of such 1-to-5 networks of women form a women (health) development team withleadership comprising the leaders of the 1-to-5 networks.
x Use the family to increase the care seeking behavior of the community regarding
MNCH
x Promote the available services delivered at the community and health facility level
including iCCM, CBNC, skill birth etc
x Introduce new health cultures that significantly reduce the under five mortality likethe kangaroo mother care.

Health Facilities (health Centers & Hospitals)
x
x
x
x
x
x
x

Create awareness of newborn and child survival agenda for their staff
Incorporate MNCH activities into their annual plans
Improve quality of services in their facility
Regularly update/build capacity of their staff on current practices
Ensure availability of essential commodities &equipment
Conduct regular MNCH death reviews
Provide mentoring support for lower level health facilities

Health Training Institutions & Professional Associations
These include medical and allied professional training institutions, and professional associationin the field of MNCH namely, the Ethiopian Pediatric Society (EPS), Ethiopian Society of
Obstetrics and Gynecology (ESOG), Ethiopian Public Health Association (EPHA), Public Health
Officers Association (PHOA), Ethiopian Nurse-midwives Association, Ethiopian Nurse
Association, Ethiopian Pharmacists Association and etc.
In the Ethiopian context, the role of these institutions is more or less similar and their support
focuses mainly in the following areas:x Advocacy for the adoption of favorable health policies for mothers and children
x Advise the FMOH for adoption of evidence-based MNCH interventions
x Capacity building of health cadres through both pre-service and in-service trainings
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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

x
x
x
x
x

Develop and update national preventive/promotive and curative guidelines & training
packages
Provide supportive supervision and mentoring for quality improvement
Support improvement of quality of MNCH services at all levels of the health care system
Document best practices and conduct operational researches to guide implementation
policy directions
Conduct monitoring and evaluation of MNCH program implementation

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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

8: MONITORING & EVALUATION
Successful implementation of the newborn and child survival strategy will rely on robust
Monitoring and Evaluation system. Hence, Monitoring and evaluation will be an integral part ofthe strategy. Continuous monitoring of progresses and evaluations of outcome and impacts will
provide an evidence-based decision for effective, efficient and synergistic implementation ofprograms. Moreover, it will be integrated into knowledge management efforts that will help
document lessons and sharing of experiences both nationally and to international arena.
Building strong monitoring, evaluation and knowledge management system requires effective
partnership and coordination among various departments within the FMOH and with local andinternational health development partners. In this regard, the National Newborn and Childsurvival Technical Working Group (NNCSTWG) under the chairpersonship of the FMOH should
lead the coordination of partners involved in newborn and child health in Ethiopia. As some of
the newborn and child health interventions are very much intertwined with maternal healthinterventions there should be strong integration of the partners working on newborn/childhealth and maternal health. In addition the NNCSTWG should work closely with the Policy
planning directorate in the FMOH, EPHI, Universities and other agencies engaged in healthresearches to ensure there is regular measure of the progress made in the implementation of
the strategy.
The newborn and child survival interventions adopted by the strategy (Table 1) and, selectedindicators outlined for monitoring the progress of implementation of the strategy (Annex I)
provide guidance for action and accountability at all levels within the health system. Existingroutine HMIS system will be strengthened, as it will be the main source of data for routine
tracking of performance of most of the interventions listed in the strategy. The MNCH
scorecard will also be updated to reflect the new high impact interventions and used to trackprogress made by regional states and districts to track performance with emphasis on ensuring
equity in access and use of high impact newborn and child survival interventions.
A set of high-priority indicators and operational targets will be objectively measured (Annex I)
and used for monitoring and evaluation purposes, in order to understand the scale andoutcomes of implementation; and used for evidence-based decisions.
The monitoring and evaluation of activities is broadly divided in two: regular performancetracking system and operations research, studies and evaluation.

8.1 Regular performance tracking system
Supervision will be essential at and between various levels of the health system, and especiallyfor the success of programs. Frequent and regular supervision helps to identify problems early58

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

on and take immediate remedial action. Therefore, all related programs should develop acommon supervisory mechanism and supervisory checklist with attendant human resources
and financial commitment to produce a sustainable supervisory mechanism for expanded
access to interventions for maternal, newborn and child health.
Review meetings will be conducted on a regular bases at all levels of health system to review
progresses. The review meeting will be held at the national, regional, Zonal, woreda and PHCU
level at different time intervals. During these meetings, performance of plans and targets will
be reviewed; opportunities, challenges and solutions will be identified; and successes, bestpractices and lessons learnt will be shared. The FMOH, RHBs, ZHD, WorHO and the PHCU willlead the organization of the review meetings at their respective levels.
Services and facilities should generate reliable routine data at various levels. The data should be
primarily utilized by generating unit for local decision-making and passed to the next level
without delay. To ensure quality control in M&E, an independent verification system will beestablished. The main mechanism to improve quality of data generated through routine HMIS
will be use of the data for decision-making (program improvement). Effort will be made to
improve data use for program improvement at different levels along with using independent
data quality monitoring mechanisms (such as LQAS).
HMIS data will be used to fathom progresses of activities of those indicators that are tracked by
the system on regular basis. Information not captured through HMIS will be tracked throughbuilding national data base system integrated from various sources including joint and regularsupervision checklist, and performance review meetings and training databases.

8.2 Operations research, studies and evaluation.
Surveys/studies/supervision/reports will also be used to assess the progresses made in theimplementation of the newborn and child survival interventions, outcomes and impacts ofinterventions.
The existing national surveys and evaluations that can be used to review the performance ofthe newborn and child survival strategy include EDHS, Ethiopia Service Provision Assessment(ESPA+) Annual SARA Surveys, Malaria indicator surveys, Immunization coverage surveys andother program specific studies such as ICCM and CBNC evaluations will be used to review
progresses.
FMOH will also strengthen its partnership with local and international health research centers
and universities to make use of the evidences they generate to inform the implementation of
the strategy and triangulate the reports that come from the health system.

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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

9: COSTING AND IMPACT ESTIMATIONThe Lives Saved Tool (LiST) was used to compute the resource requirements and expected
outcomes/impacts for implementing this newborn and child survival strategy. LiST is a childsurvival projection modeling tool that allows users to create short and medium term plans for
scaling up essential health services. It is a bottom-up tool that allows for modeling basedon population demographics, disease and health profiles, clinical practices, service provisionand coverage. It helps to identify the resource requirements for building and maintaining theinfrastructure, training, deploying and retaining the health workforce, availing medicines andsupplies and other aspects of the health system management including equipment, logistics,
health information and health financing. Prior to the costing, it was agreed to estimate theimpact of the optimal and the medium scenario as described in previous sections. Optimal
scenario assumes that most required resources are available and that acceleration towards
universal health coverage (UHC) is possible. In medium scenario, there is an assumption that
acceleration will not be possible and that objectives of optimal scenario will be met in 2025.
The following table summarizes the results of the impact analysis for the two scenarios.
Table 4: Impact estimation by optimal and medium scenario of implementation
Scenarios

2015

2016

2017

2018

2019

2020

Under five mortality rate (deaths per 1,000 live births)

63

63

63

63

63

63

Infant mortality rate (deaths per 1,000 live births)

44

44

44

44

44

44

Neonatal mortality rate (deaths per 1,000 live births)

28

28

28

28

28

28

Under five mortality rate (deaths per 1,000 live births)

57

50

44

37

33

29

Infant mortality rate (deaths per 1,000 live births)

41

36

32

26

23

20

Neonatal mortality rate (deaths per 1,000 live births)

26

23

20

15

13

11

Under five mortality rate (deaths per 1,000 live births)

60

56

52

49

46

40

Infant mortality rate (deaths per 1,000 live births)

44

41

38

36

34

29

Neonatal mortality rate (deaths per 1,000 live births)

28

27

24

23

22

18

Base Projection

Optimal scenario

Medium Scenario

As illustrated in the following graph, objectives set under the optimal scenario will allow
Ethiopia reduce its under-five mortality level much faster from 63 per 1000 live births to 29
between 2015 and 2020, if all of the objectives set to increase access/coverage to achieving
health and nutrition high impact interventions goals are met. The bulk of the lives saving comesfrom effective strategies to reduce newborn mortality rates by 63% (from 29 per 1000 live
births in 2014 to 11).
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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

Fig 9: Under-five mortality rate (deaths per 1,000 live births)

9.1 Costing methodology
For both scenarios, interventions are costed using the ingredients or bottom-up approach. Bothtotal and incremental costs are calculated based on drugs and supplies costs. Besides estimates
are provided from the staff time requirements linked to each intervention, including thenumber of visits (and hospital days where necessary) per average case. Other cost items such as
training, IEC or supervision are also taken into account.
The following cost estimate is based on:
x
x
x
x
x
x
x

The best accessed information on disease profiles
Used official figures for base year population demographics
Assumed that facilities are functioning
Assumed that the minimum required staffs are in place
National protocols and expert opinions are used for clinical practices
Expansion targets are set to meet the standards as based on population figures andother set criteria
Service coverage targets are set in line with the visioning exercise of achieving
impacts that are comparable to middle income countries by 2025/35, in line with thenational HSTP

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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

N.B The cost included in this strategy excludes the Infrastructure, WASH, reproductive andmaternal health and nutrition interventions that have impacts on survival and health ofnewborns and children but linking the target and costing to the specific programs is ensured.

9.3 Costing results
The following tables and graphic summarize the results from key resource estimations for
newborn and child health programs. Under the optimal scenario, Ethiopia need to mobilize US$
1.16 billion (ETB 23.2 billion) in five year period to contribute to the saving of about 368,378
under-five deaths, of which 167,597 are newborns. In average, this scenario requires US$ 1.99
(ETB 40) per capita per year and it is estimated that 60% of this amount should be spent on
drug and supply, 32% on staff related, 7% in other recurrent cost, and 1% in capital costs.
Fig 10: Total Newborn and Child Survival Strategy budget per capita (USD)

Based on recent analysis from the National Health Account 2011, the total expenditure on childsurvival is around US$ 2.49 per capita (12% of $US 20.77 spent per child), of which about 48%
came from the households, 25% from the Government and 27% from the rest of the world.
In the following medium scenario, Ethiopia need to mobilize US$ 1.06 billion (ETB 21.2 billion)
in five year period to contribute to the saving of about 229,967 under-five deaths, of which
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National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

84,449 are newborns. In average, this scenario requires US$ 1.80 (ETB 36) per capita annuallyand it is suggested that 60% of this amount should be spent on drug and supply, 32% on staff
related, and 8% in other recurrent cost.
9.4 Limitations of current cost estimates

x
x
x
x

Estimations were dependent on available data inputs, including unit costs, and mayneed further updating them with the latest available, with a potential for significant
variations in associated costs
Need additional analysis on potential source of funding for child survival and newborn
programs
The may be a need to adjust targets considering feasibility of implementation of someof the interventions and availability of financial space
Impact of the newborn and child survival strategy was projected with the assumptionthat family planning, maternal health, nutrition, and other relevant sectors will perform
to the optimum accordingly

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10: REFERENCES
UN Inter-agency Group for Child Mortality Estimation, (2014) Levels & Trends in Child Mortality,
UNICEF
World Health Organization, (2014) Every Newborn: an action plan to end preventable deaths,
Geneva: WHOFederal Ministry of Health, (2005) National Strategy for child Survival in Ethiopia (2005 – 2015),
Addis Ababa, FMOH
Federal Democratic Republic of Ethiopia, (2008) Summary and Statistical Report of the 2007
Population and Housing Census: population size by age and sex, CSA projection for 2014, Addis
Ababa, FDRE
Central Statistical Agency, (2014), Mini Demographic Health Survey 2014, Addis Ababa, CSA
World Health Organization (2014), World Health Statistics 2014, Geneva, WHO
Federal Ministry of Health(2014/15), JSC report for 2014/15, Addis Ababa, FMOH
UN Inter-agency Group for Child Mortality Estimation, (2013) Levels & Trends in Child
Mortality, UNICEF
Central Statistical Agency, ICF International (2011), Ethiopia Demographic and Health Survey
2011, , Addis Ababa, Calverton, CSA
Gunther F. et al (2011), The effect of water and sanitation on child health: evidence from thedemographic and health surveys 1986–2007, International journal of Epidemiology
2011;40:1196–1204, Oxford University Press
Count down to 2015, (2014), filling the gap for woment and children health, the 2014 report,
Geneva, WHO
Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, GranthamMcGregor S, Katz J, Martorell R, Uauy R, and the Maternal and Child Nutrition Study Group(2013). Maternal and child undernutrition and overweight in low-income and middle-income
countries. The Lancet series on Maternal and Child Nutrition
Liu L. et al. (2012). Global, regional, and national causes of child mortality in 2000–2010: an
updated systematic analysis. The Lancet. doi:10.1016/S0140-6736(12)60560-1.
Nathan P. Miller (2013), Qualitative assessment of care seeking for diarrhoea, pneumonia andmalaria in Oromia IIP_JHU, Baltimore, Maryland
Federal Ministry Of Health (2014), HSDP-IV Annual Performance Report 2013/2014, Addis
Ababa, FMOH
FDRE Ministry of Health (2014), Ethiopia’s Fifthe National Health Accounts 210/2011, Addis
Ababa, FMOH
FMOH (draft) (2014), Success factors in women and children’s health: Mapping Pathways to
Progress Ethiopia, PMNCH 2014, Addis Ababa, Ethiopia.
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FDRE MOH(2010), Health Sector Development Program IV (2010/11 – 2014/15), Addis Ababa,
FMOH
EFDRE MOH (2012), Primary Health Care Unit Linkage and Referral, 2012, Addis Ababa, MOH
FDRE MOH (2007), Health Extension Program in Ethiopia: Profile. Health and Education Center, ,Addis Ababa, FMOH
Federal Democratic Republic of Ethiopia Ministry of Health: EFY 2005 (2012/13) HSDP IV Annual
Performance Report, Addis Ababa, FMOH
FDRE MoWYCA (2014), Nationwide Women Development Army Organization and
Implementation Manual
FDRE Ministry of Health (2014), HSDP IV Annual Performance Report (2013/14), Addis Ababa,
FMOH
FDRE Ministry of Health (2012), Community mobilization and sensitization implementation
guide, Addis Ababa, FMOH
Federal Democratic Republic of Ethiopia Ministry of Health (2013): EFY 2005 (2012/13) HSDP IV
Annual Performance Report Version1, Addis Ababa, FMOH
FDRE Ministry of Health (2015), Draft Health Sector Transformation Plan (2015/16 – 2019/20),
Addis Ababa, FMOH
The Partnership for Maternal, Newborn & Child Health (2011), A Global Review of the Key
Interventions Related to Reproductive, Maternal, Newborn and Child Health (Rmnch ). Geneva,
Switzerland: PMNCH.
The Lancet Series (2007), Continuum of care for maternal, newborn, and child health: fromslogan to service delivery, Lancet 2007; 370: 1358–69, Elsevier Limited
The Lancet Series (2014), Every Newborn Series, Lancet 2014, Elsevier Limited
The Lancet Series (2008), Maternal and child Under nutrition, Lancet 2008, Elsevier Limited
The Lancet Series (2008), Alma-Ata: Rebirth and Revision, Lancet 2008, Elsevier Limited
The Lancet Series (2005), Neonatal Survival Series, Lancet 2005, Elsevier Limited
The Lancet Series (2008), Child survival, Lancet 2003, Elsevier Limited
FDRE MoH(2012), Road map for accelerating the reduction of maternal and newborn morbidity
and mortality in Ethiopia, Addis Ababa, FMOH
FDRE MoH(2014), National Malaria Strategic Plan (2014 – 2020), Addis Abab, FMOH
FDRE MoH(2011), NATIONAL EPI - COMPREHENSIVE MULTI-YEAR PLAN (2011 – 2015),Addis
Ababa, Ethiopia
FDRE MoH(2013), National Nutrition Program (2013– 2015), Addis Abab, FMOH
FDRE MoH(2006), National Reproductive Health Strategy (2006 -2013), Addis Ababa, FMOH
Central Statistical Agency, ORC Macro (2001), Ethiopia Demographic and Health Survey 2000, ,Addis Ababa, Calverton, CSA
65

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

Central Statistical Agency, ORC Macro (2006), Ethiopia Demographic and Health Survey 2005, ,Addis Ababa, Calverton, CSA
FDRE MoH(2014), HIV investment Case For Ethiopia (2015- 2020), Addis Ababa, FMOH
FDRE National HAPCO (2014), Country progress report on the HIV response, Addis Ababa, FMOH
FDRE FMOH (2015), Envisioning Ethiopia’s Path towards universal health coverage throughstrengthening primary health care (draft), Addis Ababa, FMOH
FDRE MOH (2012), The national strategic plan for elimination of mother to child transmission of
HIV (e-MTCT of HIV) (2013 – 2015), Addis Ababa, FMOH
Transitional Government of Ethiopia (1993), Health Policy of the transitional government ofEthiopia, Addis Ababa, Ethiopia
FDRE MoH (2005), National Implementation plan for community based case management ofcommon childhood illness, Addis Ababa, FMOH
FDRE MoH (2012), Community based implementation guideline, Addis Ababa, FMOH
WHO/UNICEF (2002), IMCI Adaptation guide, Geneva, Department of CAH/WHO
EHNRI, FMoH (20014), The Cost of Hunger in Ethiopia: Implication for the growth andtransformation of Ethiopia, Addis Ababa, FMOH
FDRE MoH (2011), National Malaria Indicator Survey, Addis Ababa, FMOH
FDRE MoH (2012), National EPI coverage Survey, Addis Ababa, FMOH
FDRE MoH (2013/14), Health and Health Related Indicators, Addis Ababa, FMOH
FDRE MoH (2005), Health Extension Program Implementation Guideline, Addis Ababa, FMOH

66

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

Interventions
Contraceptive Prevalence Rate

Indicators

DHS, HH surveys

Data source

YearlyYearlyYearly5 yearly

5 yearly

Yearly5 yearly

5 yearly
3 yearly
5 yearly

5 yearly

15%

10 %

0%

No data

15 %

20%

55 %

34%

68 %

35 %

32%

42 %

95%

95%

90%

90%

90%

95%

80%

100%

95%

90%

80%

95%

55%

Baseline 2020
2013/14 targets

Yearly, 5
yearly15%

5 yearly

Yearly, 5
yearlyTiming

11: ANNEXESANNEX 1 - Intervention packages and selected indicators for monitoring the strategy
Continuum ofcare level
Pre-pregnancy Family Planning

Pregnancy

Birth &
Postnatal

Antenatal care
Proportion of pregnant women who received
DHS, HH surveys
ANC 4+
ITN for pregnant mother
Proportion of pregnant women who slept under DHS, Malaria
ITN the previous night
Indicator survey
TT immunization for
Percentage of newborns protected against
DHS, EPI surveys
neonatal tetanus protection tetanus
Prevention and treatment of Percentage ofpregnant women who receive Iron DHS
iron deficiency anemia in
supplementation
pregnancy
PMTCT
Proportion of HIV+ pregnant women receiving HMIS
complete ARV course
Supplementary feeding for Percentage of malnourished pregnant and
DHS, HH surveys
malnourished pregnant and lactating women receiving supplementary
lactating women
feeding
Skilled delivery care
Proportion of births attended by skilled
DHS, HH surveys
attendant (health personnel)
Neonatal resuscitation
Proportion of newborns who were not breathing HMIS, surveys
spontaneously/crying at birth for whom
resuscitation (actions) WITH BAG AND MASK
were initiated immediately
Steroid for Preterm labor
Percentage of women with Preterm labor (<34 HMIS, surveys
weeks of gestation) receive steroid
Management of PROM
Percentage Preterm prolonged rupture of
HMIS
membranes treated with antibiotics
Thermal care for thePercentageof newborns dried after birth (dried Surveys, DHS
newborn: dried
with dry cloth and wrapped with another dry
one)
Percentage of newborns for whom bathing was Surveys, DHS
delayed for at least 24 hours after birthThermal care for the
newborn: delayed bath67

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020% children treated for pneumonia at community DHS, HH surveys
level

Thermal care for thePercentage of newborns who were placed skin Surveys, DHS
newborn: skin to skinto skin on the mothers’ abdomen or chest
contact
immediately after delivery
Cord care for the newborn: Percentage of newborns who have received cord HMIS reports
clean cutting and tie
care: cut with clean instrument and tied with
DHS/Surveys
clean tie
Cord care for the newborn: Number of newborns that received at least one HMIS reports
Chlorhexidine
dose of CHX to the cord on the first day after
DHS/Surveys
birth
Early initiation of breast
Proportion of newborn put to breast within an DHS, HH surveys
feedinghour of birth
Birth weight
Percentage of live births with a reported birth DHS, HH surveys
weightKangaroo mother care
Percentage of low birth weight and premature DHS, HH surveys
newborns for whom KMC was initiatedPostnatal care: for the
Proportion of mothers who received postnatal DHS, HH surveys
mothercare within two days of birth
Postnatal care for the
Proportion of newborns who received postnatal DHS, HH surveys
newborncare within two days of birthExclusive breastfeeding for Proportion of children exclusively breastfeed for DHS, HH surveys
children 0-6 months
the first 6 months
Continued breastfeeding for Proportion of children aged 20 to 23 months
DHS, HH surveys
Infancy and children 20 to 23 months
receiving breast milk.
Childhood Complementary feeding
Proportion of children 6–23 months of age who DHS, HH surveys(minimum acceptable diet) receive a minimum acceptable diet
ITN for under five children Proportion of children<5 who slept under ITN
DHS, HH surveys
the previous night
Proportion of Households covered with IRS (in DHS, HH surveys
IRS targeted areas)% of newborns with severe bacterial infection
HMIS, Surveys
managed with antibiotics at community level
Indoor Residual Spraying(IRS)
Newborn sepsis
management (severebacterial infection)
Community-based
Pneumonia treatment forchildren68Yearly5 yearly

5 yearly

5 yearly

5 yearly

5 yearly

5 Yearly

5 yearly

5 yearly

5 yearly

5 yearly

Yearly5 yearly

Yearly5 yearly

Yearly, 5
yearly0%6%83.8 %

38%

4%

82.2%

52 %

12% in 48
hours
12%

10%

5.2%

52 %

15%

15%

15%

80%

80%

95%

80%

30%

90%

80%

50%

80%

95%

90%

90%

95%

95%

50%

5 yearlyNational Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

Infants&
ChildrenOral Rehydration Therapy
Proportion of diarrhea cases who recieved ORT DHS, HH surveys
ORS
Proportion of diarrhea cases treated with ORS DHS, HH surveys
Zinc for diarrhea
Percentage of children with diarrhea who are
DHS, HH surveys
management
treated with Zinc at community level
Antibiotic for dysentery
Proportion of children with dysentery who
DHS, HH surveys
received antibiotics
Care seeking for fever
Proportion of children with fever during last two DHS, HH surveys
treatment
weeks who had blood test at community level
Artemisinin-based% children under five with P. Falciparum in the DHS, HH surveys
Combination Therapy forlast two weeks received ACT at community level
children
Malaria treatment with
% Children under five with P vivax in the last
DHS, HH surveys
Chloroquine
two weeks treated with chloroquine treatment
Management of complicated Proportion of complicated & severe malaria
HMIS
malariadiagnosed & treatedMeasles immunization
Proportion of children 12-23 months who
DHS, EPI coverage
received Measles vaccination
surveysPentavalent immunization Proportion of children 12-23 months vaccinated DHS, EPI coveragefor Penta 3
surveys
Fully Immunization
Proportion of children 12-23 months fully
DHS, EPI coverage
immunized
surveys
Rota immunization
Proportion of children 12-23 months vaccinated DHS, EPI coveragefor Rota
surveys
Pneumococcal
Proportion of children 12-23 months vaccinated DHS, EPI coverage
immunization
for Pneumococcal
surveys
Vitamin-A
Percentage of children aged 6-59 months who DHS, EPI coverage
received at least two doses of vitamin-A in the surveys
last 12 months
Deworming
Percentage of children aged 2-5 years of age
DHS, HH surveys
who dewormed at least two times in the last 12
months
Proportion of eligible children who are started HMIS
on ART
TB treatment success rate for children
HMIS
ART for children with
HIV/AIDS
DOTS for children

69

YearlyYearly5 yearly

5 yearly

5 yearly

5 yearly

5 yearly

5 yearly

5 yearly

Yearly5 yearly

5 yearly

5 yearly

5 yearly

5 yearly
5 yearly
5 yearly

--

9.5 %

19 %

61 %

80 %

0%

50 %

66 %

68 %

30 %

33 %

65 %

25 %

14.4 %

40%
26%
0,20 %

95%

80%

96%

95%

96%

96%

95%

96%

96%

90%

90%

100%

80%

80%

90%
90%
90%

DHS, HH surveys

DHS, HH surveys

HMIS

5 yearly
5 yearly

5 yearly

5 yearly

Yearly

84 %
63 %

8%

55%

28 %

100%
100%

93%

100%

90%

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

DHS, HH surveys
DHS, HH surveys

5 yearly
5 yearly

100%
80%

60%

100%
100%

SPA+
SPA+

13%

5 yearly
5 yearly
5 yearly

DHS, HH surveys

Proportion of HPs implementing C-HIS
DHS, HH surveys
Proportion of children whose birth is registered DHS, HH surveys

Management of Severe% of children with SAM receiving therapeutic
Acute Malnutrition
feeding
Safe drinking water
Proportion of households with access to safe
water supply
Proportion of households practicing water
treatment and safe storage at home
Sanitation
Proportion of HH with access to latrine facilities
Proportion of households properly utilizing
latrines
Availability of runiing water at health facilities
Availability of adequate and clean sanitation
facility in health facilities
Hand washing at critical time Proportion of mothers/care takers practicing
hand washing with soap at critical timeC- HIS
Birth Registration

70

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

137,457.94

2015/16

160,304.75

2016/17

203,690.25

2017/18

2,892,091.50

253,226.25

2018/19

3,734,381.69

368,617.81

2019/20

14,240,310.00

1,123,297.00

Total

20,346,913.01

2,642,224.50

5,731,249.00

2,114,635.00

2,417,074.50

4,279,263.19

542,518.19

31,198.00

2,554,537.81

3,761,321.19

428,719.31

9,336.94

48,717,446.05

2,070,922.00

3,291,200.19

396,270.81

6,701.38

13,779,545.30

71,032,373.94

701,829.50

3,283,879.44

364,029.31

5,691.38

10,135,494.00

24,093,525.90

3,896,273.00

468,957.38

383,097.38

4,821.38

8,893,115.50

16,185,782.30

995,933.06

18,777,529.01

369,257.38

4,646.94

7,863,694.00

12,751,916.80

891,158.81

4,853,276.13

286,424.38

Clean birth practices

8,045,597.25

9,820,081.81

905,718.31

3,779,947.44

244,453.38

ANNEX 2 – Cost estimates by Intervention packages (Optimal Scenario in USD)
Periconceptual
Ectopic pregnancy casemanagement
Pregnancy
RoutineTT - Tetanus toxoid
vaccination
Syphilis detection andtreatment

Immediate assessment and

8,181,067.13

651,339.81

3,479,729.44

ChildbirthClean postnatal practices

452,123.00

3,215,966.44

Feeding and supplements

Postnatal care

Preventive

Promotion of breastfeeding

Breastfeeding

Neonatal resuscitation

stimulation

Chlorhexidine

3,448,609.56

Complementary feeding--

71

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

education only

Hygienic disposal ofHand washing with soap

2,161,394.44

357,690.13

1,941,767.81

1,068,584.50

2,650,154.81

1,918,314.50

354,920.00

1,592,735.31

898,419.50

2,986,145.31

1,970,286.00

403,741.00

1,442,515.81

801,200.00

3,355,270.31

2,014,305.50

458,945.50

1,180,018.31

596,541.50

4,441,217.38

2,395,903.56

616,374.38

857,693.75

258,578.50

10,460,204.00

2,191,671.00

7,014,730.99

3,623,324.00

WASH*

BCG
2,692,476.19

40,405,790.90

11,456,022.40

36,280,278.60

15,662,033.38

2,335,680.94

13,365,067.90

37,763,306.60

15,809,881.88

2,475,474.94

15,303,967.90

39,245,032.10

15,953,092.88

3,066,890.88

20,409,168.80

47,698,218.80

18,788,079.44

12,441,841.01

71,457,087.10

201,392,627.00

84,290,371.02

16,125,264.00

Vaccines

interventions

Other promotive

Otherchildren's stools

Polio

Pneumococcal
10,922,860.10

2,193,422.94

HPV

Men A

MR vaccine

Polio campagn

Measles campagn

-

-

-

-

10,331,574.00

32,525,084.00

-

-

-

-

-

10,282,164.00

32,548,532.00

372,415.00

254,620.00

1,087,027.00

1,087,027.00

473,910.00

10,165,397.00

32,467,491.00

790,836.00

538,225.00

2,213,425.00

2,213,425.00

979,372.00

9,975,054.00

32,251,616.00

1,262,240.00

855,109.00

3,380,621.00

3,380,621.00

1,519,840.00

9,698,619.00

31,867,925.00

2,425,491.00

1,647,954.00

6,681,073.00

6,681,073.00

2,973,122.00

50,452,808.00

161,660,648.00

18,077,283.44

Rotavirus
2,370,371.31

IPV-

Pentavalent

Measles

Heptitis B birth dose
Curative after birth
Neonatal

72Oral antibiotics

KMC - Kangaroo mother

Thermal care

600,206.31

977,036.94

5,134,004.88

445,072.50

10,276,212.06

69,790.50

2,952,615.94

14,117.25

51,200.88

541,664.38

585,446.69

21,131,935.56

488,719.25

1,147,441.38

5,955,900.88

448,746.63

10,428,092.63

54,334.38

2,626,015.69

14,313.44

49,384.81

511,354.81

553,393.25

15,169,485.19

21,710,301.56

463,534.25

1,397,033.88

7,315,699.38

505,193.63

12,093,540.13

45,786.38

2,717,839.69

14,003.94

54,512.81

554,977.31

605,051.75

17,265,123.69

22,302,274.56

435,840.25

1,614,962.38

8,643,303.88

558,327.63

14,034,376.13

32,710.88

2,816,651.19

10,919.94

59,841.31

600,319.81

662,958.25

23,167,105.69

26,814,616.63

468,465.94

2,123,081.44

11,774,045.00

717,019.63

19,322,402.06

14,252.88

3,423,765.50

4,629.44

76,986.19

761,850.69

857,600.06

82,140,390.01

115,859,923.00

2,456,766.00

7,259,556.02

38,822,954.02

2,674,360.02

66,154,623.01

216,875.00

14,536,888.01

57,984.00

291,926.00

2,970,167.00

3,264,450.00

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

Injectable antibiotics

23,900,794.69

13,280,170.19

compounds for malaria

Antimalarials - Artemesininof measles

Vitamin A - for treatment

pneumonia in children

management ofOral antibiotics : case

Other infectious diseases

diarrhea

Zinc - for treatment ofof dysentery

Antibiotics - for treatment

solution

ORS - oral rehydration

Diarrhea

sepsis/pneumonia

prematurity

Full supportive care for

care

Full supportive care for

13,258,505.25

Therapeutic feeding - for

73

1.51

208,397,014.89
1.62

200,601,736.90
1.72

218,841,607.89

National Strategy for Newborn and Child Survival in Ethiopia, 2015-2020

severe wasting
Total
Per capita

74

2.03

237,903,553.39
2.33

294,833,135.15

1,160,577,048.23

1.99