Introduction: Ensuring access to universal primary health care is essential to secure a safe and pleasant motherhood and to provide compassionate care for mothers and newborns.However, inequalities in the access to maternal health services still remain a prominent problem in many countries. As part of reducing inequalities, Ethiopia launched the Health Extension Program (HEP) in 2003. The HEP is a community based program designed with a defined package of essential promotive, preventive and basic curative services targeting households, particularly mothers and children. Despite the construction of over 600 health posts and deploying more than 1200 Health Extension Workers (HEWs), preliminary data suggests a low utilization of maternal health care services. This thesis explores the HEP contribution in improving women’s access to maternal health care, and the reasons for the low use of maternal health care services from the perspectives of the involved actors in the Tigray region in Ethiopia. The five dimensions of access were used as a framework to explore the access to maternal health care utilization in this setting. Methods: A total of four districts were included in the study. Both quantitative and qualitative methods were applied. In the first sub-study, we assessed the HEP and its association with change in the utilization of antenatal, delivery and postnatal care services. Retrospective longitudinal data for 10 years was extracted from three selected districts and checked for accuracy. Segmented linear regression technique was used to control the secular trends adjusted for correlation of the data. For the second sub-study, we conducted a cross sectional survey with 1115 women (aged 15-49 years who had given birth within five years prior to the survey period) to determine the prevalence of antenatal care and institutional delivery utilization and explore their determinant factors of low utilization. For the third sub-study, we conducted six focus group discussions (FGDs) with a total of 51 women to explore women’s experiences of childbirth and maternal care. An interview with eight HEWs and four midwives were carried out to capture health workers’ perspective on access to maternal health care services in the fourth sub-study. Grounded theory for the former, and thematic analysis for the latter were used for the analysis. Main findings: The finding of the first sub-study showed a statistically significant upward trend for delivery care (DC) and postnatal care (PNC) in all facilities during the HEP late implementation period (July 2008-June 2012). In addition, a substantial trend of antenatal care (ANC) service use was observed at health centres after the intervention. In the second sub-study, the determinant predictors for ANC utilization were: proximity to health facilities, to be married, ≥5 years of education and having non-farming husbands. The last three factors were also significantly associated with institutional delivery, but also lower parity, previous history of obstructed/prolonged labour and ANC counselling. Findings from the qualitative studies pointed out that elderly women influenced women’s decision making about where to give birth. Women were mostly positive about giving birth at health facilities, but were concerned about the poor quality of care, inaccessibility and unavailability of transport. From the health workers’ perspective: specialized performance of hospital services, community assistance during referral and an increased awareness among women regarding the benefits of giving birth at a health facility were perceived as facilitators for institutional deliveries. Poor perceived competence of HEWs, poor conditions of health care facilities and inaccessibility of transportation, among others, were perceived as barriers for giving birth at health facilities. Conclusion: Overall, this research revealed a considerable contribution of the HEP in improving the access and coverage of maternal health services (ANC, DC and PNC). However, cultural traditions, scattered localities, mountainous roads without adequate transportation and low quality of care are still the major obstacles to accessing the services. Mechanisms need to be designed to enable health facility access of safe delivery for women in hard to reach areas, improving the proficiency of health workers and introducing a women centered approach that enhances acceptability of the services. / ሽፋን መሰረታዊ ክንክን ጥዕና ምዕባይ ድሕንነት ኣዴታትን ህፃናትን ንኽረጋገፅ ዝለዓለ ተራ ከምዘለዎ ይፍለጥ፡፡ ይኹንደኣምበር ግልጋሎት ጥዕና ኣዴታት ብማዕረ ኣብ ምብፃሕን ብምዕሩይ ኣገባብ ኣብ ምሃብን ብዙሓት ሃገራት እናተፀገማ እየን፡፡ ነዚ ዘይምዕሩይን ማዕረ ዘይኾነን ኣዋህባ ግልጋሎት ጥዕና ንምምሕያሽ ኣብ ሃገርና (ኢትዮጵያ) ብ1994-1995 (ብአቆፃፅራ ግእዝ) ዝተኣታተወ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ቤተሰብ (Health Extension Program/HEP) 10 ዓመታት ኣሕሊፉ ይርከብ፡፡ ፕሮግራም ምግፋሕ ጥሙር ጥዕና (HEP)፣ ሕብረተሰብ መሰረት ዝገበረ-ምክልኻል ሕማማትን ምስጓም ጥዕናን - ምትእትታው ግልጋሎት ሕክምና ቀለልቲ ሕማማትን ብፍላይ ድማ ንኣዴታትን ህፃናትን ትኹረት ብምግባር ስድራ ቤት ብምሕቋፍ ዝንቀሳቐስ ፕሮግራም እዩ፡፡ እዚ ፕሮግራም ንምትግባር ኣብ ክልል ትግራይ ልዕሊ 600 ኬላታት ጥዕና ተሃኒፀን፡፡ ልዕሊ 1200 ሞያተኛታት ጥሙር ጥዕና እውን ሰልጢነን እየን፡፡ ክልተ ሞያተኛታት ኣብ ሓደ ኬላ ጥዕና ተመዲበን ካብ 5000-7000 በዝሒ ንዘለዎ ሕብረተሰብ ግልጋሎት እናሃባ ይርከባ፡፡ እንተኾነ ግን ዝተፈላለዩ መፅናዕታታት ከምዘመላኽትዎ ግልጋሎት ኣዴታት ጥዕና (ወሊድን ድሕሪ ወሊድን) ትሑት ሽፋን ከምዘለዎ ይሕበር፡፡ ዕላማ እዚ ዝገበርናዮ መፅናዕቲ እውን ኩነታት እቲ ግልጋሎት ብኣሃዝ ንምዕቃንን ከምኡ እውን ምኽንያታት እቲ ትሑት ግልጋሎት ንምድህሳስን እዩ፡፡ ኣብዚ መፅናዕቲ እዚ ምኽንያታት ትሑት ሽፋን ግልጋሎት ክንክን ጥንሲ ወሊድን ድሕረ ወሊድን እንታይ ምዃኑ ካብ ሕሉፍ ልምዲ (ተሞክሮ) ኣዴታትን ሰብ ሞያ ጥዕናን ብዝርዝር ብምድህሳስ - ፕሮግራም ምግፋሕ ጥሙር ጥዕና ንቐረብ ግልጋሎት ኣዴታት ጥዕና ንምምሕያሽ ዘለዎ ኣስተዋፅኦ እንታይ ከምዝመስል ተተንቲኑ ቐሪቡ ኣሎ፡፡ እቲ ቀረብ ግልጋሎት ጥዕና ሓሙሽተ መዐቀኒታት ብዘለዎ ፍሬም ዎርክ እዩ ተዳህሲሱ እቶም ሓሙሽተ መመዘኒታት 1. ቅርበት ትካል ጥዕናን ሰብ ሞያ ጥዕናን ንተገልገልቲ 2. ህልውነት ሰብ ሞያ ጥዕናን ናውትን ድሌት ተገልገልትን 3. ሰብ ሞያ ጥዕና ብተገልገልቲ ዘለዎም ተቐባልነት 4. ትካል ጥዕና ንድሌት ተገልገልቲ ንምዕጋብ ዘለዎ ድልውነት 5. ተገልገልቲ ወፃኢታት ሕክምና ንምሽፋን/ንምኽፋል ዘለዎም ድሌትን ዓቕምን እዮም፡፡ እዞም ሓሙሽተ መዐቀኒታት መሰረት ዝገበሩ ኣርባዕተ ዓይነታዊን አሃዛዊን ሜላታት ብምጥቃም ዝተኻየዱ መፅናዕትታት ኣብ ኣብ 4ተ ወረዳታት ትግራይ እዮም ተኻይዶም፡፡ ኣብቲ ቀዳማይ መፅናዕቲ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ቤተሰብ (HEP) ኣብ ምምሕያሽ ክንክን ጥንሲ-ወሊድን-ድሕረ ወሊድን ግልጋሎት ዘምፅኦ ለውጢ ኣብ ሰለስተ ወረዳታት (ጋንታአፈሹም፤ ክልተ ኣውላዕሎ፣ ሕንጣሎ ዋጅራት) ንዝሓለፉ 10 ዓመታት ኣብ ዝተዋህበ ግልጋሎት ብምድራኽ እዩ ዳህሰሳ ተኻይዱ፡፡ ትኽክለኛነት እቲ ፀብፃብ እውን ካብ ትካላት ጥዕና ዝተልኣኸ ወርሓዊ ኣብ ወረዳ ምስ ዘሎ ፀብፃብ ብምንፅፃር ንኽረጋግፅ ተገይሩ እዩ፡፡ እቲ ካልኣይ መፅናዕቲ ኣብ ወረዳ ሰሓርቲ ሳምረ ካብ 19 ጣብያታት ካብ ዝተመረፃ 30 ቑሸታት ዕድሚአን ካብ 15-49 ዓመት ምስ ዝኾና 1115 ደቂኣንስትዮ ኣስታት 30 ደቓይቕ ዝወደአ ቃለ መሕትት ብምኽያድ እዩ ዳህሰሳ ተኻይዱ፡፡ ኣብ ወሊድ ግልጋሎት ዘሎ ልምድን ተሞክሮን ንምድህሳስ 51 ኣዴታት ዝተሳተፋሉ ሽዱሽተ ጉጅላዊ ምይይጥ በቲ ሳልሳይ መፅናዕቲ ምርምር ዝተፈፀመ እንትኾን ምስ ሸሞንተ ሞያተኛታት ጥሙር ጥዕናን ኣርባዕተ ነርስ መዋልዳንን ቃለ መሕትት ብምኽያድ እቲ 4ይ ምርምር/መፅናዕቲ ተፈፂሙ እዩ፡፡ ውፅኢት ቀዳማይ መፅናዕታዊ ፅሑፍ ኣብዚ ቐዳማይ መፅናዕቲ እቶም ዝተአከቡ መረዳእታት ኣብ ሰለስተ ደረጃታት - ቅድመ ፕሮግራም-ፕሮግራም-ድሕረ ፕሮግራም ብዝብል ዝተመቐሉ እዮም፡፡ እቲ ቐንዲ ዕላማ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ድሕሪ ምጅማር ዝተራእየ ለውጢ ንምፍታሽ እዩ፡፡ ኣብ ድሕሪ እቲ ፕሮግራም ካብ 2001-2004 ዓ/ም ብዝተኻየዱ ንጥፈታት ጥዕና ግልጋሎት ወሊድን ድሕረ ወሊድን ኣብ ኩለን ትካላት ጥዕና ካብ ዓመት ናብ ዓመት ልዑል ኣዝማሚያ እናርኣየ ከምዝኸደ ብስታቲስቲካዊ መረዳእታ ንምርግጋፅ ተኻኢሉ እዩ፡፡ ብተመሳሳሊ ኣብዚ ወቕቲ እዚ ኣዝማሚያ ግልጋሎት ክንክን ጥንሲ ኣብ ጥዕና ጣቢያታት ጥራሕ እናለዓለ ከምዝኸደ ውፅኢት እቲ መፅናዕቲ የረድእ፡፡ እቲ መፅናዕቲ ከም ዘረድኦ ሽፋን ክንክን ጥንሲ ብ1995 ካብ ዝነበሮ 28.2% ብ2004 ናብ 46.7 ክምዝለዓለ፤ ግልጋሎት ወሊድ ብ1995 ካብ ዝነበሮ 5% ዝነበረ ናብ 23% ከምዝደየበ ድሕረ ወሊድ ግልጋሎት እውን 11% ዝነበረ ናብ 41% ከምዝለዓለ ንምርዳእ ተኻኢሉ ኣሎ፡፡ ውፅኢት ካልኣይ መፅናዕታዊ ፅሑፍ ኣዴታት ግልጋሎት ክንክን ጥንሲ ኣብ ጥዕና ጣቢያ ንኽጥቀማ ቅርበት ትካላት ጥዕና ንመንበሪ ገዛውቲ፣ ሓዳር ምግባር፣ ልዕሊ 5 ዓመት ስሩዕ ትምህርቲ ምምሃርን ካብ ሕርሻ ወፃኢ ኣብ ካልእ ስራሕቲ ዝተዋፈሩ ሰብ ሓዳር ምህላው ወሰንቲ ኣካላት ምዃኖም በቲ ዝተገብረ ካልኣይ መፅናዕቲ ተረጋጊፁ፡፡ ብተመሳሳሊ ኣብ እዋን ክንክን ጥንሲ ንኣዴታት ምኽሪ ግልጋሎት ምሃብ ቅድመ ታሪኽ ዝንጉዕ ሕርሲ ወይ ሃልኪ ምንባር እውን ኣብ ትካላት ጥዕና ወሊድ ግልጋሎት ንኽመሓየሽ ወሰንቲ ኩነታት ከምዝኾኑ በቲ መፅናዕቲ ተረጋጊፁ፡፡ ብሓፈሻ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ቤተሰብ (HEP) ቀረብ ግልጋሎት ጥዕናን ሽፋን ክንክን ጥንሲ ወሊድን ድሕረ ወሊድ ግልጋሎትን ኣብ ምምሕያሽ ዝተፃወቶ ተራ ትርጉም ዘለዎ ምዃኑ በቲ ዝገበርናዮ መፅናዕቲ ንምርዳእ ተኻኢሉ ኣሎ፡፡ እንተኾነ ግን ባህላዊን ልማዳዊን ኩነታት (ኣብ ገዛ ክትወልድ ምድላይ- ነፍሰፁር ዓይኒሰብ ከይረኽባ ኢልካ ምእማን) - ተበቲኖም ዝሰፈሩ ነበርቲ ምህላው - ኣፀገምቲን ዓቐብ ቁልቁልን ጎቦታትን ዝበዝሖም መንገድታትን እኹል መጉዓዝያ ዘይምህላውን ቀንዲ ሃልኪታትን ዕንቅፋታትን እቲ ዝወሃብ ግልጋሎት ምዃኖም ኣብዚ መፅናዕቲ ተገሊፁ እዩ፡፡ ብተወሳኺ ኣብ ላዕለዎት ትካላት ጥዕና ዘይብሩህ ገፅን ሰሓባይ ኣቀራርባ ሰብ ሞያ ጥዕና ዘይምህላውን ተቐባልነት ዘይብሎም ባህሪያት ምንፅብራቕን ነቲ ግልጋሎት ዝዓዘዘ ዕንቅፋት ከምዘለዎ በቲ መፅናዕቲ ንምርዳእ ተኻኢሉ እዩ፡፡ ማይን መብራህትን ዝኣመሰሉ ትሕቲ ቕርፂ ኣብ ኬላታት ጥዕና ዘይምህላዉ ኣዴታት ኣብ ቀረበአን ዘሎ ትካል ጥዕና ንኽወልዳ ዘየተባብዕ ከምዝኾነ እውን ተሓቢሩ እዩ፡፡ ውፅኢት ሳልሳይን ራብዓይን መፅናዕታዊ ፅሑፍ ኣብ ሳልሳይ መፅናዕቲ ምስ ኣዴታት ብዝተገበረ ምይይጥ - ኣደ እትወልደሉ ቦታ ባዕላ ንኽትውስን ከምእነሓጎታት ዝመሰላ ዕድመ ዝደፍኣ ኣዴታትን ፀቕጢ (ተፅእኖ) ከምዝግበረላ እቶም መፅናዕቲታት ይሕብሩ፡፡ ዋላ አኳ ኣብ ትካል ጥዕና ብዛዕባ ምውላድ ኣዎንታዊ ኣረኣእያ ኣዴታት ዝዓዘዘ እንተኾነ ብዛዕባ ድኹም ኣዋህባ አገልግሎት ጥዕና ኣዝዩ ከምዘተሓሳስበን እቲ መፅናዕቲ ይገልፅ፡፡ ትካል ጥዕና ናብ መንበሪ ኣዴታት ዘለዎ ርሕቐትን መጓዓዓዚ ዘይምርካብ ዝኣመሰሉ ፀገማት ከምዘገድስወን እውን እቲ መፅናዕቲ ይሕብር፡፡ ኣብቲ ራብዓይ መፅናዕቲ ብወገን ሞያተኛታት ጥሙር ጥዕናን ነርስ መዋልዳንን ብዝተገበረ ምይይጥ - ኣብ ሆስፒታል ዝዋሃቡ ዝሐሹ ግልጋሎት ኣዴታት ካብ ታሕተዋይ ትካል ጥዕና ናብ ሆስፒታላት ሪፈር እንትበሃላ ኣብ ምጉዕዓዝ ብሕብረተሰብ ዝግበር ምትሕግጋዝ ከምኡ እውን እናዓበየ ዝኸይድ ዘሎ ግንዛበ ሕብረተሰብ ኣዴታት ኣብ ትካል ጥዕና ንኽወልዳ መሳለጢ ከምዝኾነ እቲ ፅንዓት የረድእ፡፡ ዓቕሚ ምንኣስ ሞያተኛታት ጥሙር ሞያተኛታት ጥሙር ጥዕናን ነርስ መዋልዳንን - ድኹም ኩነታት ትካል ጥዕናን (ሕፅረት ናውቲ ጥዕና ምህላዉ - ትሕቲ ቅርፂ ዘይምምላእ) ፀገም መጉዓዝያን እውን ኣዴታት ኣብ ትካል ጥዕና ንኸይወልዳ ዕንቅፋታት ከምዝኾነ እቲ ፅንዓት የመላኽት፡፡ መጠቓለሊ እቶም ዝተጠቐሱ ዕንቅፋታትን ፀገማትን ብምንካይ ቀረብ ወሊድ ግልጋሎት ጥዕና ንምዕባይ እዞም ዝስዕቡ ፃዕሪታት ምክያድ ይግባእ፡፡ ኣብ ጎቦታትን ኣዝዩ ርሑቕን ኣፀገምትን ዝሰፈረ ሕብረተሰብ ካብቲ ልሙድ ዝተፈለየ ቀረብ ግልጋሎት ጥዕና ምሃብ (ንኣብነት ካብ ጥዕና ጣቢያ ኣዝየን ዝርሕቓ ኬላታት ጥዕና ክእለት ዘለወን ነርስ መዋልዳን (midwives) ምምዳብ - ኣደ ማእኸል ዝገበረ ግልጋሎት ንኽወሃብ ሰብ ሞያ ጥዕና ብዓቕሚ ንኽዓብዩ ምግባርን ነቶም ሓሙሽተ መዐቀኒታት ቀረብ ግልጋሎት ብምምላእ ኣብቲ ሕብረተሰብ ተቐባልነት እቲ ግልጋሎት ክዓቢ ምግባርን፡፡

Magister Public Health - MPH / The Health Extension Program (HEP) was initiated under the Health Sector Development Program (HSDP II) in 2002/03. The central philosophy of these initiatives was based on the belief that if the right knowledge and skill is transferred, each household can take responsibility for producing and maintaining its own health. The HEP is delivered through Health Extension Workers (HEWs), who are local women and have completed grade 10. Recruitment of these workers is conducted by kebele (village) and woreda (district) councils. Following this they are provided with a one year training prior to being employed by the district health office. The HEP guideline states that all HEWs should be assigned to a health post within their own community.The rationale for this requirement is that health policy makers and mangers believe that the deployment of non-local HEWs results in poor performance and turnover. However, there is no evidence to support this assumption. This study was conducted to better understand the effect of place of selection on the performance of health posts and turnover of Health Extension Workers in Jimma Zone, Ethiopia.A cross sectional analytical study design was utilized to assess the effect of place of selection on the performance of health posts and turnover of HEWs in a randomly selected sample of six districts of Jimma Zone. A systematic record review on the activity reports for the Ethiopian Fiscal Year (EFY) 2003 was conducted on all selected health posts in Jimma Zone(239 randomly selected health posts from all functional rural and urban health posts in Jimma Zone) obtained from the district health office. Descriptive statistics was computed to describe the socio demographic characteristics and the level of performance. Chi-square test was performed to test the relationship amongst the variables.The finding from this study showed that HEWs who are assigned outside of their communities performed as well or even better than those recruited from the same communities.The differences between the relationship of staff turnover and retention couldn‟t be estimated due to limited availability of information related to this factor. Overall, despite the widely held opinion among policy makers that recruiting HEWs from the same community enhances their performance; there is little empirical evidence to support this argument based on the findings from this study. Thus, it is essential to explore additional factors and criteria in the selection and recruitment process beyond residence-based measures in the expectation to enhance the performance of the HEWs.