Background: Availing equitable and affordable health services for citizens is becoming a problem for governments of developing countries. In Ethiopia, the government has been implementing fee waiver scheme since 1998 to advance the health access by the poor, though it is still a crucial challenge of the health sector. Purpose: The intent of the study was to evaluate the effectiveness of fee waiver scheme in improving access to health by the poor in Addis Ababa and to propose implementation framework to improve its outcome. Method: This study employed qualitative research approach to evaluate the program effectiveness and to propose implementation framework in two phases. Exploratory and descriptive case study designs, and Delphi techniques were utilized to evaluate the scheme’s effectiveness and to validate the proposed implementation framework. The researcher employed purposive and convenience sampling methods to sample the study populations, and used Atlas ti 7.5 software to analyze the findings. Result: This study revealed that the commencement of the scheme has benefited considerable poor population in the city. However, its effectiveness in terms of addressing the needy population, services coverage and protecting the poor from financial hardship is not yet achieved. Poor health facilities capacity, poor program management and lack of comprehensive monitoring and accountability system were found major factors that affected its success. As a result, the researcher proposed an implementation framework with the aim of addressing these problems. Conclusion: Achieving Universal Health Coverage without addressing the indigents’ health need is impossible. Lack of comprehensive health services, in adequate population coverage and poor financial protection were among the major findings. Hence, prior attentions should be given to equip health facilities with necessary infrastructures and ensure the inclusion of all needy populations through effective monitoring, governance and leadership mechanisms to improve its intended outcomes. If utilized properly, the findings and the implementation framework of this study will serve as valuable resources for immediate decisions and directions by the policy makers / Health Studies / D. Litt. et Phil. (Health Studies)

Stigma and discrimination (SAD) attached to Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) has been recognised as a major obstacle to HIV prevention, treatment, care and support throughout the world. SAD is more devastating when it occurs in health care settings where it is least expected. Health care providers (HCPs) are supposed to provide physical, social and psychological support to people living with HIV (PLWHA) but HIV and AIDS-related SAD has been extensively documented among the HCPs. Different studies have pointed out that there are three major actionable causes of HIV-related SAD in health care settings. These are lack of awareness among HCPs, fear of casual contacts and associating the SAD to immoral behaviour. The main objective of the current study is to determine the magnitude of HIV and AIDS-related SAD and its associated factors in hospitals and then to propose appropriate SAD reduction-intervention strategy in the health care settings. The study employed pre-test-post-test design with non-equivalent control group. Two paradigms were used in this study including quantitative and qualitative approaches. The sampling method for the quantitative part of the study was probability sampling in which the respondents were randomly selected using stratified sampling technique. The study was able to determine the magnitude of HIV and AIDS-related SAD among the HCPs. Moreover, the study has identified the factors that are attributed to the prevalence of SAD in the hospitals. The major factors identified for causing the SAD in the hospitals were sex, age, work experience, low level of knowledge, negative attitudes and percieved risk of HIV infection of some HCPs toward the PLWHA. The intervention made on the respondents in the treatment group was able to reduce the overall prevalence of the SAD among the HCPs. The study suggests that to reduce the SAD, HIV and AIDS-related trainings before and after graduation is critical to improve the knowledge, attitudes and practices of the HCPs. Besides, ensuring the availability of the protective supplies in hospitals is crucial in reducing the fear of HIV infection among the HCPs while providing care for HIV positive patients. Effective implementation of the hospital policies, strategies, guidelines and protocols along with good institutional support is also vital in creating safe and user-friendly hospitals for PLWHA / Health Studies / D.Litt. et Phil. (Health Studies)

Stigma and discrimination (SAD) attached to Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) has been recognised as a major obstacle to HIV prevention, treatment, care and support throughout the world. SAD is more devastating when it occurs in health care settings where it is least expected. Health care providers (HCPs) are supposed to provide physical, social and psychological support to people living with HIV (PLWHA) but HIV and AIDS-related SAD has been extensively documented among the HCPs. Different studies have pointed out that there are three major actionable causes of HIV-related SAD in health care settings. These are lack of awareness among HCPs, fear of casual contacts and associating the SAD to immoral behaviour. The main objective of the current study is to determine the magnitude of HIV and AIDS-related SAD and its associated factors in hospitals and then to propose appropriate SAD reduction-intervention strategy in the health care settings. The study employed pre-test-post-test design with non-equivalent control group. Two paradigms were used in this study including quantitative and qualitative approaches. The sampling method for the quantitative part of the study was probability sampling in which the respondents were randomly selected using stratified sampling technique. The study was able to determine the magnitude of HIV and AIDS-related SAD among the HCPs. Moreover, the study has identified the factors that are attributed to the prevalence of SAD in the hospitals. The major factors identified for causing the SAD in the hospitals were sex, age, work experience, low level of knowledge, negative attitudes and percieved risk of HIV infection of some HCPs toward the PLWHA. The intervention made on the respondents in the treatment group was able to reduce the overall prevalence of the SAD among the HCPs. The study suggests that to reduce the SAD, HIV and AIDS-related trainings before and after graduation is critical to improve the knowledge, attitudes and practices of the HCPs. Besides, ensuring the availability of the protective supplies in hospitals is crucial in reducing the fear of HIV infection among the HCPs while providing care for HIV positive patients. Effective implementation of the hospital policies, strategies, guidelines and protocols along with good institutional support is also vital in creating safe and user-friendly hospitals for PLWHA / Health Studies / D.Litt. et Phil. (Health Studies)

The purpose of this study was to explore the level of integration of health promotion and disease prevention services with the curative care provided at hospitals and health centres in Addis Ababa, and to propose recommendations that could improve such an integrated health service. A quantitative approach, using an exploratory and descriptive design was applied at 22 public health facilities in Addis Ababa followed by the Delphi technique to reach consensus on ways to improve the integration of health promotion, preventive and curative care. An integrated health service (IHS) framework was used as the conceptual framework upon which the study was based. Multistage sampling involving stratified simple random sampling was applied to select hospitals and health centres while a systematic sampling technique was used to sample patients from the outpatient and inpatient medical departments. Data was collected by means of two questionnaires from patients and health service managers, respectively, following which two Delphi rounds with experts resulted in agreement on a contextually accepted integrated framework. The findings revealed that promotive and preventive services for chronic diseases were not optimally integrated in the routine health care services of the health facilities. Most health facilities lacked skilled health professionals, adequate medication and equipment to provide a comprehensive integrated service. The study emphasized the need for health service providers to undergo a paradigm shift and additional training in order to provide a comprehensive, patient-centred, integrated health service instead of only treating patients’ complaints. To assist this approach, the study affirmed the Integrated Health Service (IHS) framework as a tool which comprehensively demonstrates the cause, effect and progression of chronic diseases and the appropriate interventions which health professionals can apply in managing diseases or their risk factors. Recommendations for effective, integrated promotive and preventive health care, included the development of guidelines, protocols and policy documents for cultivating a healthy lifestyle, adopting effective disease prevention approaches, re-designing medical school curriculums, and staffing health facilities with trained and specialized staff, capacitating health facilities with the necessary equipment, medication and supplies that would enable the provision of an integrated health care service. / Health Studies / D. Litt. et Phil. (Health Studies)

Background: Preconception care (PCC) is highly recommended evidence-based intervention to optimize women’s health in particular and in so doing reduce the incidences of adverse pregnancy outcomes (APO). PCC targets modification of risk factors to APO occurring before and just at early weeks of conception. Nevertheless, in Ethiopia, the need to implement PCC as part of the continuums of the comprehensive Maternal, Neonatal and Child Health Care services is not yet studied. Purpose/Aim of the study: This study aimed to develop a guideline to assist the incorporation of PCC in Ethiopian health system thereby reduce the highly incident APOs in the country, which is the purpose of the study. Methodology: This study applied the explanatory sequential mixed method to determine the determinants to the non-implementation PCC in Ethiopia. In addition, a policy document analysis was conducted to identify the existence of policy guiding the implementation of PCC in Ethiopia. Finally, the study applied a Delphi technique to increase the utility and acceptance of the guideline developed. The study was guided by a theory based framework called a Framework for Determinants of Innovation Processes (FDOIP). RESULT: Nearly all (84.7%) of the healthcare providers (HCPs) never ever practiced PCC. Even among those who ever practiced, the majority (74%), practiced it poorly. More than two third (68.6%) had poor PCC knowledge. HCP’s with good PCC knowledge had likely hood of practicing PCC by four times greater than those with poor PCC knowledge (AOR=4.4, 95% CI: 2.5-7.6). The policy document analysis identified the absence of policy guiding the practice of PCC in Ethiopia. The HCP’s curriculums also didn’t include PCC. The determinants to non-implementation of PCC, as perceived by the qualitative study participants include absence of national PCC policy , absence of PCC guideline, lack of institutional PCC plan, presence of other competing demand, lack of laboratory facilities and setup, lack of accountable body, absence of Individual or organization introduced PCC to the country, absence of trained manpower on PCC, absence of known expert in PCC, Poor public awareness about preconception health and PCC, Unplanned Pregnancy and poor health seeking behaviour. CONCLUSION The study revealed the absence of a standard and complete PCC practices by the HCPs. Nearly all HCPs never ever implement PCC. Even those very few practitioners were found practicing PCC poorly that is in a substandard, incidental, and in an inconsistent way. There is no formal policy document guiding the implementation of in Ethiopia. The HCPs training curriculum didn’t include PCC. The guideline developed base on the study findings of the study recommended to incorporating PCC in Ethiopia health system. / Health Studies / D. Litt. et Phil. (Health Studies)

Distinct dimensions of quality vary in importance depending on the context in which quality assurance effort takes place. Working through the process of quality assurance and continuous quality improvement may create an environment for transforming the health services and achieving positive health outcome goals. Substantial improvements have been observed in the coverage and access to health service delivery in Ethiopia. However, the quality of care has been lagging behind. The purpose of this study was to develop guidelines for care to enhance quality health services at Gindabarat District, Oromia Regional State, Ethiopia. The study followed a mixed method approach. The participants were purposively included in the study based on their availability, from a total of 7 government health facilities from the Gindabarat District. Self-administered questionnaires and interviews were used to collect data from samples of 127 health care workers and 29 health facilities managers, respectively. Collected data were analysed using SPSS Version 24 and ATLAS TI 8 respectively. The results revealed barriers towards quality health services delivery which were lack of equipment and supplies (inadequacy of blocks, materials, medical equipment; lack of sustainable supplies of drugs); inadequate human resources (low retention of skilled staff; absence of focal person assigned for quality improvement; shortages of health workers); absence of standard operating procedures (protocols, guidelines and manuals); and dissatisfaction of health care providers with services provided at the District. Based on the results, guidelines were developed to enhance quality health care delivery. The reccommendations were aimed at improvement approaches at all levels of health service delivery. / Health Studies / D.Litt. et Phil. (Health Studies)

Introduction: Evidences indicate that human immuno-deficiency virus (HIV) and diabetes (DM) impact pregnancy outcomes but no experience on the integrated service delivery of HIV, DM and pregnancy care. This study explored the domains and levels of integration among DM, HIV and pregnancy care to prepare a service delivery model in Ethiopia. Methods: A sequential exploratory mixed method and the integration theoretical framework guided the study. An exploratory qualitative phase used focused group discussion, in-depth interview and observation to explore the level of integration and to refine a questionnaire for the quantitative phase. The data were transcribed and coded for theme-based analysis. The descriptive quantitative phase described HIV, DM and pregnancy care services, and determined the burden of DM among HIV patients and the prevalence of pregnancy and pregnancy outcomes. Data was analysed using Epi-info. The findings were triangulated, discussed and interpreted. Results: Seven themes were generated: joint plan, shared budget, monitoring system, structural location, the need of policy guide, the practice of integrated service delivery and suggested integration approaches. A coordinated HIV and pregnancy care services were noted. There was a linkage between diabetes and HIV, and diabetes and pregnancy care. The 1.5% of diabetes among HIV, the low number of pregnancies per a mother in diabetes (1.8) and HIV (1.3); the high adverse pregnancy outcomes among HIV (13.4% abortion, 12.4% low birth weight (LBW), 3.5% pre-term birth, 2.1% congenital malformation) and diabetes (3.2% big baby, 3.2% LBW, 3.1% Cesarean-section); the respective absent and low (16.2%) diabetes screening service at anti-natal and HIV clinics, the absent pregnancy care service for diabetic females justified the development of the tripartite integrated service delivery model of diabetes, HIV and pregnancy care. Conclusions: The model suggests active diabetes screening, evaluation and treatment at HIV and antenatal clinics. It considers the coordination between non-communicable diseases (NCD), HIV and maternal health units. Pregnancy care could be coordinated at HIV and NCD units. Full integration can be practiced between HIV and pregnancy care units. Preparing policy guide, building the capacity of health providers, advocating and piloting the model may be prioritized before the implementation of the model. / Health Studies / D. Litt. et Phil. (Health Studies)

Introduction: HIV referral and linkage system in many countries in general and in Ethiopia in particular was poorly characterised by low linkage rate. The purpose of this study was to analyses factors associated with poor referral and linkage system and develop strategies to improve the system. Methods: A sequential mixed method approach using exploratory descriptive study design was employed. The study was conducted in Addis Ababa, Ethiopia and it was conducted in two phases. Phase I involved data collection and analysis as evidence for the development of strategies while phase II was the development of strategies. For phase I, data were collected in steps 1 and 2 using individual interviews and focus group discussions respectively. The study participants were programme owners and partners who were supporting facilities during the data collection period in step 1 and health care providers in step 2. A total of 4 individual interviews and 3 FGDs were conducted with purposively selected participants. Data were analysed using computer assisted software called OpenCode version 4.2. Results: The findings revealed five themes namely, issues of referral and linkage practice, ensuring linkage through communication, issues of health care, issues of health care system and issues of partnerships and Health Bureau. Many gaps that affected the referral system were identified and in phase II, nine strategies were developed to strengthen the referral and linkage system. Conclusion:The results of this study highlighted weaknesses in the referral and linkage system of the HIV positive clients from counselling and testing services to chronic care and proposed strategies to strengthen those weaknesses. Measures to operationalise those strategies are also proposed. The successful implementation of the proposed strategies depends on the support of the ministry of health and regional bureau in terms of resources and the readiness of the health care providers to adhere to the proposed measures. Intervention research is needed to test the effectiveness of the proposed strategies. / Health Studies / D. Litt. et Phil. (Health Studies)