Jimma University College Of Public Health and Medical Sciences Department of Health Services Management

Project proposal on Improving skilled delivery in selected woredas, Jimma zone

Submitted to: international development research center Toronto- Canada

Submitted from: Jimma Zonal Health Department Jimma-Ethiopia

Jimma University College Of Public Health and Medical Sciences Department of Health Services Management

Project proposal on Improving skilled delivery in Jimma zone

BY: Group-II- year-I MPH/HSM

Group Members: Ashenafi Habtamu Gebayehu Tsega Melaku Haile Mustafa Geleto Tesfaye Dagne

To be submitted to department of health services management in partial fulfillment of advanced health system management course May 2012 Jimma, Ethiopia

Project Overview Project Title Implementing agency Address Tel P O.box Contact Person Project Location Area Coverage Beneficiaries Target/Group Direct Indirect Duration of the project Date of Commencement Funding Agency Collaborating agencies Project Cost: CRDC Jimma University, UNFPA Increasing Skilled Delivery Jimma Zonal Health Department Jimma +251911911209 378 Tesfaye Dagne, General manager

EXCUTIVE SUMMARY
With a population of 74.5 million in mid-2005 and 2.8 million births per year, Ethiopias estimated maternal mortality ratio (MMR) of 673-720 per 100,000 live births in 2005 (2, 3) equates with 19,000 maternal deaths per year. Ethiopia is one of the top five countries with the highest number of maternal deaths worldwide. Contributing factors to this death toll include early age at marriage, high fertility, low availability and use of maternal health services, extremely low population density (72/km2) with few roads and vehicles for the 85% of the population living in rural areas, and low literacy of women with 89% of the poorest quintile unable to read. Fifty-one percent of births to urban mothers were attended by a health professional and 50 percent were delivered in a health facility, compared with 5 percent and 4 percent, respectively, of births to rural women. Mothers residing in Addis Ababa are the most likely to be attended to at delivery by a health professional (84 percent) and the most likely to deliver in a health facility (82 percent) compared with mothers of other regions.

In order to reduce maternal mortality rate and improving maternal health, safe and skilled institutional delivery is crucial. So, this project was proposed to improve skilled delivery in Jimma zone through provision of Delivery kit, training of health workers from each institution in Jimma Zone, creating community awareness and strengthening of referral system. More over there will be linkage with ANC and Postnatal care to follow the pregnancy and related complication before delivery and complication that may appear following delivery.

This will be achieved through involvement of community and working closely with different stake holders. The curriculum of training will be designed in collaboration with Jimma University while the procurement of delivery kit will be made agreement with PSI Ethiopia.

The project will achieve that all health facilities with full delivery kit and Health workers trained on skilled delivery, increased skilled delivery >=80% and involvement of men in institutional delivery>=80%. Finally death of mother related to delivery to <1%.

This project will be implemented by Jimma zone Health Office for improvement of skilled delivery in Jimma Zone. The project will be active for five years starting from September, 2012 and the budget required for entire project was $4,375,456.5. The project will directly link Mother and child health services and routine activities in the health facilities to ensure sustainability of the services once project cease.

Background Information
Jimma zone is located in Oromia Regional State and situated at about 356kms away from Addis Ababa city, the capital of Ethiopia, in the Southwest direction. Jimma has the total area of 19,293.5 Square Kilometers. The zone has 17 rural Woredas and 1 urban Woreda with total of 548 kebeles. 515 of them rural and 30 of them are urban kebeles. According to the census of 2007 total population of the zone is estimated to be more than 2.7 million and the zone has also population density of about 13 people per Sq.Km. Geographically, the zone is located at 7013-8056N latitude and 35052-37037E longitude. Topographically, Jimma zone might be divided into escarpment and alluvial plains. Elevation within the zone ranges from the lowest 880 meters above sea Level of the Gibe and Gojebvalley in Dedo and Omo nada Woreda respectively to the highest 3344 meters above sea Level of May- gudo in Omo nada woreda. Ecologically, the zone has Weina Dega 62%,Kola 22% and Dega 16%.which receives moderately heavy rainfall throughout the year. The mean annual rainfall in the zone is 1200 2000mm. Socio economically as other part of the country in Jimma Zone the majority of the population relay on backward traditional agricultural farming and on top of this out of the whole Woreda of the zone 1/3 of them (Mana, Goma, Limu-kosa, Gumay, Shabe-Sombo and Gera) are also known by their natural Coffee production which plays a great role in national exports.

Boundaries of Jimma Zone

Jimma zone is bounded by South-west Shoa and West Shoa zones in north; SNNPR in south; Iluababor and East-Wollega zones in west; and SNNPR in east. Jimma zone is one of the biggest zones in Oromia Region with 2,729,513 populations and with yearly population increment of 2.9% (CSA, July 2004). The compositions of the population with respect to broader age groups by 2007 were: Less than one year- 84,332 Less than five year- 489,891 Less than fifteen year- 489,892 Women of childbearing age - 603,222

Pregnant women 102,502 Total households-577152

Concerning Human power and Health institution of Jimma Zone; there are Total 2707 of human power. Among them 1074 are HEWs and the remaining 1633 are other health professionals. Jimma zone owns one district hospital, 73 health centers and 529 health posts.

Tiro Afeta

Gera Dedo

Maternal Health
With a population of 74.5 million in mid-2005 and 2.8 million births per year (1, 2), Ethiopias estimated maternal mortality ratio (MMR) of 673-720 per 100,000 live births in 2005 (2, 3) equates with 19,000 maternal deaths per year. Ethiopia is one of the top five countries with the highest number of maternal deaths worldwide.

Contributing factors to this death toll include early age at marriage, high fertility, low availability and use of maternal health services, extremely low population density (72/km2) with few roads and vehicles for the 85% of the population living in rural areas, and low literacy of women with 89% of the poorest quintile unable to read (2). Measures of development for Ethiopia, whether it be the Human Development Index (169th out of 177 countries), the Human Poverty Index (HPI-1) (105th of 108), or the Gender Empowerment Measure (GEM) (72nd of 93) (4) imply a level of development that is affected by and affects health, particularly maternal health.

Yet the Ethiopian government was one of the first in Africa to make a strong commitment to the United Nations inspired Millennium Development Goals (MDGs) by making the MDG targets central to its national development strategy (5). The MDG 5 goal is to improve maternal health but meeting the MDG 5 target of reduction of maternal mortality by three quarters between 1990 and 2015, would mean reducing Ethiopias MMR to 218/100,000 live births by 2015 from the 1990 estimate of 871.

A 2008 mid-term review of the Health Sector Development Programme (HSDP-III) found that this is unlikely to happen given the programs present status (6). In this paper, we review the status of the maternal indicators for MDG 5, specifically the data on the MMR and on use of skilled birth attendants.

Fifty-one percent of births to urban mothers were attended by a health professional and 50 percent were delivered in a health facility, compared with 5 percent and 4 percent, respectively, of births to rural women. Mothers residing in Addis Ababa are the most likely to be attended to at delivery by a health professional (84 percent) and the most likely to deliver in a health facility (82 percent) compared with mothers of other regions. Mothers educational status is highly correlated with whether delivery is assisted by a health professional and whether the birth is delivered in a health facility. For example, 5 percent of births to mothers with no

education were attended by a health professional and delivered in a health facility compared with between 70 and 72 percent of births to mothers with some secondary education. Less than one percent of women were attended by a HEW at delivery.

Statement of Problem
Skilled care refers to the care provided to a woman and her newborn during pregnancy, childbirth and immediately after birth by a skilled birth attendant and the support of a functioning health system, including transport and referral facilities for emergency obstetric care. A skilled attendant is an accredited health professional such as a midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns (WHO, 2004). One of the most daunting challenges facing the world today in the field of health is the issue of maternal mortality. Of all the Millennium Development Goals, the least progress has been made on goal Number Five (MDG 5): Reducing maternal mortality by three-quarters by the year 2015. The World Health Organization (WHO) estimates that about 536,000 women of reproductive age die each year from pregnancy related complications (WHO, 2008). Nearly all of these deaths (99%) occur in the developing world (WHO, 2005). These deaths are almost equally divided between Africa (251,000) and Asia (253,000), with about 4% (22,000) occurring in Latin America and the Caribbean and less than 1% (2,500) in the more developed regions of the world. Maternal mortality rate also shows the same disparity among regions. The world figure is estimated to be 400 per 100,000 live births. It is higher in Africa (830), followed by Asia (330), Oceania (240), Latin America and the Caribbean (190), and at the bottom the developed countries (20) (AbouZahr, 2003). Globally, at least 160 million women become pregnant annually. Of these, 15% develop a serious complication. Over 30 million women in the developing world suffer from serious diseases and disabilities which include uterine prolapsed, pelvic inflammatory disease, fistula, incontinence, infertility, and pain during sexual intercourse as a result of inadequate or inappropriate care during pregnancy, delivery or the first critical hours after birth (WHO, 2005). In addition to the above consequences, maternal death has also an impact in the health and well-being of families, communities and in general in the social and economic situation of the societies. Each year an estimated US $15.5 billion is lost in potential productivity when mothers and newborns die (WHO 2005). When a woman dies in childbirth, her infant and any other childrens survival is threatened. Infants without mother are more likely to die within two years. Children up to 10 years whose mothers die are 3 to

10 times more likely to die within two years than children living with mothers. Every year an additional 2 million children worldwide are maternal orphans (WHO, 2005). Maternal death has long term effects on a childs education and health. When a mother dies, older children often leave school to support their family. Children without a mother are less likely to be immunized, and are more likely to suffer from malnutrition (WHO, 2005). In addition to the tragedy of these preventable deaths, high maternal mortality comes with a high cost to the rest of society. Costs are both direct, including the cost of health care (either to families or to the health system), and indirect, in the form of income and productivity lost for both the mother and the family (child health, growth, and education all suffer when mothers die) (Gill et al. 2007). For women aged 15 to 19 in Africa, giving birth is the leading cause of death. Over the previous few decades remarkable progress has been made in almost every sector of development. More children now survive in developing countries than ever before and more of them now go to school. Unfortunately the situation in terms of maternal mortality has not changed much for many developing countries. The world has utterly failed to do much in this respect. This has been rightly called 'scandal of the century'(Graham 1998). Maternal death is an indicator of disparity and inequity between men and women and its extent a sign of womens place in society and their access to social, health, and nutrition services and to economic opportunities (WHO, 1999). There are many factors that affect the outcome of pregnancy from the onset of any obstetric complication. The outcome is most adversely affected by delayed treatment. Delay in treatment is the result of many factors. These delays are described as the three phases of delay (Thaddeus S, 1990): Delay I: Lack of information and adequate knowledge about danger signals during pregnancy and labor; cultural/ traditional practices that restrict women from seeking health care; lack of money Delay II: Out of reach of health facilities; poor road, communication network, community support mechanisms Delay III: Inadequate skilled attendants; poorly motivated staff; inadequate equipment and supplies; weak referral system, procedural guides. Studies demonstrating the high levels of maternal mortality and morbidity in developing countries and research identifying causes of maternal deaths have repeatedly emphasized the need for availability of trained personnel to attend women during labor and delivery (Fauveau et al., 1988; Fortney et al., 1988). Unfortunately skilled birth attendances are low in less developed countries Globally, it is estimated that 34% of the mothers deliver with no skilled attendant; this means there are 45 million births occurring at home without skilled health personnel each year.

Skilled attendants assist in more than 99% of births in developed countries compared with 62% in developing countries. In five countries including Ethiopia the percentage drops to less than 20% (WHO, 2005). Recent findings indicated that this figure is only 10 % in Ethiopia (EDHS, 2011) Skilled attendance at delivery is one of the key indicators to reflect progress towards the Millennium Development Goal of improving maternal health. The agreement set the goal of 40% of all births to be assisted by a skilled attendant by 2005, with 50% coverage by 2010 and 60% by 2015 among countries with very high maternal mortality. Globally, the goal is to have 80% of all births assisted by skilled attendants by 2005, 85% by 2010 and 90% by 2015 (Stanton et al, 2006). A study from South India showed that assistance during delivery can reduce the risk of obstructed labour and it is highly associated with the place of delivery (Navaneetham et al, 2000). Another study also presented the role of assisted skilled birth attendants in preventing direct and indirect cause of maternal deaths such as, infection, shock, blood loss, convulsions, and surgical procedures, such as caesarean delivery (AbouZahr, 2003). Maternal mortality and morbidity are directly and indirectly related to societal and cultural factors that impact womens health and their access to services. Thus, lack of access and control over resources, limited educational opportunities, poor nutrition, and lack of decision-making contribute significantly to adverse pregnancy related outcomes. Review of the international literature also emphasizes factors like cultural beliefs, socio-demographic status, womens autonomy, economic conditions, physical and financial accessibility, disease pattern and health service issues to be important determinants of the use of maternal health care services (Shaikh et al, 2004, AbouZahr, 2003). A study from India have pointed out that the low utilization of maternity services seems to be due to low levels of household income, high illiteracy and ignorance, and a host of traditional factors (Shariff et al, 2002). A similar study in Pakistan described poor socio-economic status, lack of physical accessibility, cultural beliefs and perceptions, low literacy level of the mothers and large family size as the leading causes of poor utilization of primary health care services (Babar et al, 2004). In another study from Ethiopia, it was observed that the use of maternal health services can be influenced by the socio demographic characteristics of women, the cultural context, and the accessibility to these services (Yared et al, 2002). In India, a study of analysis of choice of delivery location showed that maternal and, paternal education, and scheduled caste status were the predisposing factors that determined the choice of private facilities, public and home deliveries (Thind et al, 2008). In a similar way, a study from Pakistan showed that family size, parity, educational status and occupation of the head of the family were also associated with health seeking behavior in addition to age, gender and marital status (Babar et al, 2004). A study from rural Tanzania identified that ethnicity, gender of the household head, mothers education, mothers age at child

birth, socio-economic and quality of services status were important independent factors in determining the choice of delivery place Sudden onset of labour or short labour were affecting decisions towards selecting the delivery place. Selecting health facility for delivery was perceived to be more desirable for prolonged labour (Mrisho et al, 2007). In summary, the above studies have identified that the main determinants for low utilization of maternal health care services include maternal education, ethnicity, gender of the household head, mothers education, mothers age at child birth, socio-economic status, parity, accessibility and quality of health service, decision making power and experience of previous obstructed labour. The percentage of deliveries attended by skilled health professionals is taken as an indicator of maternal mortality ratio. In Ethiopia, the levels of maternal and infant mortality and morbidity are among the top five countries in the world (WHO, 2007). With the lowest rate of skilled birth attendance in the world, the lifetime risk of an Ethiopian woman dying in childbirth or from obstetrical complications is one in 40, compared to one in 6,000 in developed countries (WHO, 2010). Only 10 percent of births in the past five years were delivered by a skilled provider and half of mothers (48 percent) had their live birth protected against neonatal tetanus (EDHS, 2011). Maternal mortality ratio in Ethiopia is 470 per 100,000 live births, Infant mortality rate: 68.5 per 100,000 live births Under-five mortality rate 101 per 1,000 live births. (Margaret C. Hogan et al, 2010). The five major direct causes of maternal deaths have been documented (FMoH) and these account for 85% of causes of maternal death with abortion ranking highest at 32%, obstructed labor at 22%, sepsis 12%, hemorrhage 10%, hypertension 9% and other causes 15%. Most of these deaths could be avoided if preventive measures were taken and adequate care was delivered by skilled birth attendances. Contributing factors to maternal deaths include adolescent pregnancy, HIV/AIDS, malaria, malnutrition and harmful traditional practices (e.g. female circumcision). Other potential factors contribute to child birth and pregnancy related risks. The first is the low percentage of pregnant women who receive antenatal care from trained professionals (50.4 percent nationwide). Secondly very few births are attended by skilled professionals (15.1%). Female genital mutilation is also widely practiced, which creates greater health risks for women. The high fertility profile of the Ethiopian woman and the prevailing high-risk fertility characteristics expose the woman to repeated risks of unnecessary death. These major direct and indirect causes of death compounded by poor utilization of maternal services and lack of appropriately skilled health personnel have resulted in the high maternal mortality ratio .The MDG is to reduce MMR by three quarters between 1990 and 2015. This means a reduction of MMR from 871 per 100,000 live births in 1990 to 290 per 100,000 live births in 2015. A 2008 mid-term review of the Health Sector Development Programme

(HSDP-III) found that this is unlikely to happen given the programmes present status (HSDP III review, 2008). Reports from Jimma zone health department indicates that the skilled delivery coverage is 35.7% which is better than the country status. The report also indicates that ANC and PNC coverage of the zone are 56.3% and 78.7% respectively. Our project aims to work in four districts in Jimma zone; called Gomma, Manna, Kersa and Tiro-Afata. 237,438 people dwell in Gomma Woreda. Among them, 8073 are eligible for skilled health care. The population of Manna Woreda is 163,187 with 5548 prgnant women. Kersa Woreda has 184,043 with 6257 childbearing women. The other one, Tiro- afata Woreda, is inhabited by 146,437 people, including 4979 child bearing women. These districts were selected for the intervention because of their achievement in skilled birth attendances is poorer (their coverage is 10%, 14% 8% ,6% to Kersa, Manna, Gomma and Tiro-afeta Woredas respectively, which is lesser than the zone coverage). (jimma zone health department,2011)

TECHNICAL APPROACH AND ANTICIPATED BENEFITS

Through collaborative activities with Jimma Zone Health Desk and the selected health offices of the selected woredas, the health institutions of the districts will be capacitated through delivering refreshment trainings for the health staffs and strengthening the institutions by supplying necessary materials and equipment needed for skilled delivery. Community mobilizations will also take place to create awareness about skilled delivery among the community. In collaboration with the health extension workers, kebele administrators and other civil servants in each kebele, community conversations will be conducted to initiate the community utilize the skilled birth delivery services provided and hence increase the coverage of skilled birth attendances in the districts. Each health center will have at least two trained health care workers who deliver skilled birth attendances. In the district hospital of Jimma at least two general practitioners will also be trained to attend skilled births. The trained staffs will be paid 400.00 ETB as top up monthly to maintain their motivations. Each trainee will agree and sign to serve at least for a year to serve in the health institution that he/she was selected from. Jimma University will be the one that will deliver the trainings. If the health facilities do not have adequate human power resources, extra health care professionals will be hired. The Woreda Health Offices will be responsible for recruiting and employing the health care professionals. Our project will cover the salaries of these marginally employed health workers. To strengthen referral system between the health institutions, necessary materials such as ambulances will be supplied for each health center in the districts. We will work harmoniously with road construction authority to maintain the roads that connect kebeles with health centers and Jimma town. The community will participate in road maintaining activities. Trainings on referral situations will be given for health center skilled birth attendants.

To supply delivery kits we will work with social marketing companies, such as PSI Ethiopia, in procuring the necessary stuffs. To ensure sustainability of the benefits of the project the community will be made have feeling of ownership of the project and activities under it through continual community conversations and participation in all activities. This will make the community hand in and support the activities after the termination of the project. Ultimate Goal To Improve Skilled Delivery in four woredas of Jimma zone Project objective To capacitate Health Facilities with Human Resources and Delivery Kit Specific Objective; To supply delivery kit for all Health facilities in four woredas of Jimma Zone. To Provide training for 2 health workers per Health center on skilled delivery Increase Community awareness on benefit of skilled delivery To Strength referral system between Health centers and Hospital

Strategies used to implement the projects Communicating and cooperating with Custom and revenue minister for tax free procurement. Contracting with PSI Ethiopia for effective procurement and distribution of delivery kit Setting standards and quality of delivery kits to be procured with cooperation of Ethiopian quality assurance authority Working cooperatively with woreda administration and Road authority for maintenance of road to transport of materials to Health Facilities. Working cooperatively with woreda health office to select committed Health professional. Signing agreement with Jimma University for training of Health Professionals for both short term and long term. Working with community leaders and respected individuals. Provision of community based panel discussion and community conversation which will be leaded by respected individuals and health workers for technical assistance.

Objective 1 To supply delivery kit for all Health facilities in Jimma Zone. Strategy 1 Working cooperatively with custom and tax administration authority, zonal Health department, Woreda administration and Rural road authority for procurement baseline survey of gaps and transportation in delivery kits Activity 1 Communicating with custom and tax administration for tax free procurement and import of materials Signing with PSI Ethiopia for procurement and distribution of kits to health facilities Communicating with woreda administration and road authority for proper maintenance of road Indicators 1 Number of health facilities supplied with delivery kits

Objective 2 To Provide training for 2 health workers per Health center on skilled delivery

Strategy 2 Signing agreement with Jimma University for training of Health workers Working cooperatively with Jimma zonal Health Department for effective selection of Health workers Activity 2 Developing training manual for health workers Providing orientation for trainers on manual Selection of health workers to be trained and making agreement to serve at least one year after training Selection of 4 General Practitioners from Hospital and making agreement with them to serve in the hospital at least for 2 years Providing intensive practical based training on safe and clean delivery Provision Intensive practical based training on Comprehensive Emergency Neonatal Care.

Indicators 2

 Number of health facilities with at least two health professionals trained on safe and clean delivery. Number of Practitioners trained on Emergency Neonatal Care

Objective 3 Increase Community awareness on benefit of skilled delivery

Strategy 3 Working With Community leaders, Political, Religious, and Respected individuals in the community Using Existing Development Networks

Activities 3 Provision of TOT for community leaders, Model Households and respected individuals in the community on skilled delivery Developing and conducting community conversation on advantage of skilled delivery, especially focusing on the risk of not utilizing skilled delivery services Mainstreaming skilled delivery as one of development agenda Indicators 3 Number Of Households participated on panel discussion and community conversation Number of pregnant women attending Health Facilities for skilled delivery Objective 4 To Strength referral system between Health centers and Hospital Strategy 4 Connecting management of Health Centers with Hospital administration Procuring at least one ambulance for each woreda Activities 4 Procurement of 4 4WD Toyota Land cruiser ambulances For Hospital. Assigning four ambulances to four direction from the hospital Posting the telephone directory of all health facilities in MCH unit, Logistic & Vehicle traffic distribution manager, Manager of Hospital. Posting and distribution of Telephone number of Hospital Manager, Logistic & Vehicle traffic distribution manager and MCH head to all health facilities Providing referral guideline for all Health facilities

 Provision of regular feedback for Health Facilities

Clientele
Direct beneficiaries of this project will be womens in reproductive age groups who lives in Manna, TiroAfata, Kersa and Gomma Woredas of Jimma zone whose age is 15-49 years and has the probability to become pregnancy. This problem is selected as our project title by involving the community. The community members (especially women) are participated in project proposal development through consultation of community leaders, religious leaders, Woreda Health office, zonal health desk experts and other influential peoples. Sustainable community consultation forum will be conducted throughout project implementation/life cycle.

Methods
The project team or group members discus about project topic based on situation analysis (Brain storming ). Jimma Zone Health Department was consulted to know the magnitude of maternal and child death relate to delivery in Jimma zone and to select more affected Woredas for intervention. Fourt Woredas (Manna, TiroAfata, Kersa and Gomma ) will be primary selected for intervention because of high prevalence of complications and mortality rates of delivery related problems. Discussion was held with major sectors heads, religious leaders and community members about the issue.

Target population was identified depending on the magnitude of the problem. For target population necessary information disseminated on the importance (aim) and benefit of project. A debriefing workshop will be held by three years project manager and senior experts will be presented and discussed with all leaders across the project sites. Services center will be selected on available health center and hospital with community leaders. Training will be given for all participant including Health workers. For all reproductive age group Antenatal care (ANC) training will be provided according to guidelines. For all target populations and community members health education will be given on the importance of ANC and safe delivery benefits and where to go during delivery and other related complications . Monitoring and evaluation will be conducted according to the schedule and feedback will be sent for concerned body. Review meeting will conduct every three months. Reports will be summated every month to the program manager office. Feedback also will be given for the reports.

Staff/Administration
To run the project activities efficiently and effectively throughout the life cycle the project the following staff arrangement are needed from different type of categories.

Governing board - A nine (9) member Board made up of , Zonal administrative head (chairman), Zonal
health department head (Vice chairman), womens and children affairs office head(any delegated) and one community representatives(members), project manager (secretary) , Zonal head of Education office, zonal justices office, Zonal head of agriculture office, Zonal finance and economic department head. Responsible for sanctioning the operation of the service, providing feedback on operation, and serving as available link to the local community and project staff.

Woreda Project Coordinating committee- Nine (9) members ;- Woreda administrative head
(chairman), Woreda health office head (Vice chairman), Woreda womens and children affairs office head(any delegated) and one community representatives(members), project manager (secretary) , Woreda head of Education office, Woreda justices office, Woreda head of agriculture office, Woreda finance and economic department head. Responsible for planning, implementing and evaluating of the project in their specific Woreda.

Project manager (full time)- Responsible for hiring project staff, overseeing project development and
operation, establishing and maintaining links with local government agencies, and budget.

Administration and finance head (full time)-responsible for financial and personnel duties who is
accountable to project manager.

Program coordinator (full time)- Responsible for establishing and distributing activities among
technical workers ,the community workers, developing working relationships with formal and informal community leaders, and scheduling of services delivery centers.

Logistics and Pharmaceutical supply distribution officer (full time) - responsible to procure and
distribute drugs, medical supply and others.

Health promotion specialist (Full time) - responsible for the development of IEC/BCC materials. Monitoring and evaluation officer (full time)- responsible to observe project execution so that
potential problems can be identified in a timely manner and corrective action can be taken, when necessary, to control the execution of the project. The key benefit is that project performance is observed and measured regularly to identify variances from the project management plan the intended goals.

Training officer (full time)-responsible for the preparation of training and to keep list of trainee and
kind of training offered.

Data analyst (full time)- responsible to compile and analyze data Accountant (full time) - responsible to control, prepare for audit monthly and daily activities of financial
issue

General Service and purchasing officer (full time) - responsible for managing and purchasing
properties and responsible for logistic distribution.

Casher (full time) - responsible to pay salary, collects and store money, keeping advance payment
voucher

Driver (full time) - responsible for driving and maintaining car. Guard (full time) - responsible to keep the project property and compound as well (security issues). Executive secretary (full time) - responsible to execute the writing, documentations and other
activities given by manager and others subordinates

Cleaner (full time)-responsible to keep the cleanliness of the rooms.

Professionals needed
1. Health Officer responsible to clerk and prescribe for pregnant women according to standards.

2. Midwives responsible to conduct delivery and other related issues for the target groups. 3. Nurse responsible to give nursing care and timely follow for the target group according to the standards. 4. Environmental health - responsible to ensure infection prevention and safety practices according to guidelines. 5. Health Education and promotion Officer responsible for planning, designing, implementing, monitoring and evaluation of health education activities 6. Drugist/pharmacist responsible to store and distribute equipment and supplies 7. HEW responsible to create awareness and strengthen the referral system the health center.

Stakeholders
1.External stakeholders are;
UNICEF WHO Zonal and Woreda Education Offices Zonal and Woreda Women affairs offices Zonal and Woreda justices offices Zonal and Woreda finance and economic offices Community and religious leaders womens and community associations if any. All community members and target population.

2. Internal stakeholders
FMOH

OHB Project Governing Board (Zonal) Woreda Project Coordinating committee Zonal Health Department Woreda Health Office Health facilities at different levels Kebele Health committee

Available resources
1. Human resources
Table 1. Human resource available at Woreda No Staff 1 Health officers 6 5 3 Technical Manna Tiro-Afata Kersa Gomma 4 18 Total

2 Senior C.Nurses

31

3 4

midwives Medical Laboratory technologists

2 3

2 2

2 2

3 3

9 10

5 6

Pharmacists drugists

2 3 4

1 2 1

1 3 3

2 3 4

6 11 12

7 Environmental health officers 8 HEWs

50

52

62

78

242

total Non-technical 1 0 1 Casher Cleaners

77

73

84

105

339

17

15

15

1 1 2 1 3 Other supportive staffs Total 17 7 7 21 52 2 1 2 3 8 Guards 4 2 1 5 12

Health Facility District hospital = 2 Health Center = 63 Health post = 476

Table 2 Equipment/Supplies/Communication Sr.no 1 Item Vehicle ambulance Motorcycle number number 0 16 4 20 unit Available Needed

2 3 4

Computers with printer Photo copy machine Office furniture Tables Chairs Cap board LCD Projector

number number number

4 0

20 20

Medical Equipment Thermometer stethoscope Measuring board Measuring tap refrigerator delivery couch 16 20 40 40 number 40 40 20 60 60 20

Health Communication Materials

Telephone Tape recorder TV with DVD player Microphone

20

20

20

Budget
Table 3 Drugs, medical supply and material needed S Sr.no 1 2 3 4 5 6 7 8 9 oxytocin Canula ergometrin Gloves Auto claves Foreceps Kidney dish Cutter Bp appratus number vial box number pieces pieces box Item unit Quantity Unit price US$ Total US$

1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1

Beam balance

number

stich

roll

Scissors.

number

Surgical blade

box

gauze

roll

cotton

roll

Table 4 budget for salary budget item N sr.no descripition unit U No.of person Salary per Month(US $) YEAR 1 General manager 1 U 01 10560 YEAR 2 10560 YEAR 3 10560 US $ 31680 Implementation period Total

1 project officer 1 2 finance and 1 3 administration head Nurse 1 4 Health officer 1 5 Midwives 1 6 Envtal health 1 7 Laboratory 1 8 Field supervisor 1 9 Mobilizer 1 10 secretary 1 11 Casher 1 12 Deriver 1 13 store keeper 1 14 Cleaner 1 15 Guard 1

S$ U S$ U S$ 01 4800 4800 4800 14400 01 7200 7200 7200 21600

U US $ U US $ U US $ U US$ U US$ U US $ U US $ U US $ U US $ U US $ U US $ U US $ U

02

4800

4800

4800

14400

03

5400

5400

5400

16200

02

4800

4800

4800

14400

02

4800

4800

4800

14400

02

4800

4800

4800

14400

4800

4800

4800

14400

1200

1200

1200

3600

2040

2040

2040

6120

2400

2400

2400

7200

1800

1800

1800

5400

1800

1800

1800

5400

600

600

600

1800

600

600

600

1800

16 SUB TOTAL

US $

Table 5 supply and equipment budget SUPPPLIES AND N O EQIPMENTS Unit quantity Unit cost(US $) IMEPLEMENTAION PERIOD YEAR 1 US $ COMPUTERS 2 1 WITH PERINTER LCD projector 2 2 PHOTOCOPY 2 3 MACHINE MICROPHONE 2 4 TELEPHONE 2 5 2 6 2 7 2 8 STAIONERY 2 9 SUB TOTAL Gross CHAIRS number 20 100 2000 Cap board number 4 50 200 TABLE number 10 100 1000 number 4 100 400 number 2 600 1200 number 25 2000 50,000 number 4 2058 8232 number 20 2000 40000 YEAR 2 US $ YEAR 3 US $ Total US $

Table 6 general administration budget SBUDGET ITEM Unit Per month Implementation period total

Sr.No

DESCRIPITION n 3general administration 3Perdiem number number

(US$)

Year 1

Year 2

Year3

7406

88880

88880

88880

.1 3car rent .2 3telephone fee .3 3fuel .4 3vehicles maintenance .5 sub total 4 capacity building number person 88880 period 20,000 20,000 20,000 barrel 706 8476 8476 8476 number 300 3600 3600 3600 number 2700 32400 32400 32400

4training for health .1 professional 4 .2 4 .3 4sensitization for com .4 4 .5 4REVIEW MEETING .6 Sub total Total Contingency 10% Grand total trainers training for chw training for hew

person

17400

person

15400

person

2667

32000

32000

32000

person

48000

number

14400

14400

14400

Table 7 Budget Summary Sr.No BUDGET ITEM DESCRIPITION Year 1 1 2 Salary Supply and equipmen 3 General administration 4 5 drugs 6 7 contingency Total Capacity building Medical supply and Year 2 Year3 Unit Implementation period total

Monitoring and Evaluation

The project will be monitored by board consists of 10 members; these are: Head of Woredas Health Office Head of Zonal Health Department One Community representative from each woreda Project coordinator. There will be monthly meeting on the progress of project, strengths, weakness, opportunities and Challenges faced during implementation. Each woreda health office head will report all activities done in the reporting months. The community representatives will also report what they feel about the progress of the project will be followed by hot discussion and future direction on the challenges and difficulties.

There will be regular monthly feedback and supportive supervision for all project woredas and health facilities by Zonal MCH experts and project coordinators Moreover there will quarterly review meeting with head of health offices, Head of Health Center and Hospital director. There will be project evaluation survey at the end of second year of project life and at the end of project to determine whether the project objectives and ultimate goal achieved. The monitoring and evaluation of this project will incur 5% of the total budget approved for this project. The evaluation will be done by both internal and external evaluators. The achievement of the project will be indicated by: Percentage of Health Centers in project woreda with full delivery kit is 100% All Health Centers in the project have at least 2 trained health professionals on skilled delivery Percentage of pregnant women attending skilled delivery is >=80% Referral of complicated cases to the hospital within 2 hours >=80% Involvement of community in promotion of skilled delivery is >=85% Maternal mortality rate in project woreda reduced by 75%

Sustainability
The project implementation will be done through existing structure, no need of special human resources and health facilities for project implementation. It will be done through capacity building of health facilities with training of human resources and supplying with delivery kits. In addition Ambulance will be procured for each woredas. More over the project will supply the stock and other materials that will be enough at least for three months. The materials that was procured for project office will be given to Zonal health department Maternal and child health unit for strengthening of skilled delivery while the materials procured for woredas and Health facilities will be remain there.

CURIULUM VITAE 1. PERSONAL BACKGROUND Name Tesfaye Dagne Sex Male Date of birth 1985 G.C Marital status... Single Nationality Ethiopian Address .Jimma town/0913447032/ E-Mailtes.da08@yahoo.com

2. Educational Background S.No Educational Background 1 Primary and junior secondary school School Name Gute-andode primary school Year 185-1992 E.C Location West Shoa,Ethiopia

Secondary school education

Gindeberet High School

1993-1994 E.C

West Shoa,Ethiopia

Higher education

Jimma University

1997-1999 E.C & 2003-2004 E.c

Jimma, Ethiopia

4. QUALIFICATION MPH/health service management

3. RESARCH ACTIVITY KAP on HIV/AIDS among High school students

5. SERVICE EXPERIENCE 2 years as urban health extension professional supervisor 2 year as planning and programming health service in zonal department
6. SKILLS

Computer Literacy 7. References Ato Fisum Wasihun, zonal health department head CURIULUM VITAE 1. PERSONAL BACKGROUND NameAshenafi Habtamu Sex Male Date of birth1986 G.C Marital status. single Nationality- ETHIOPIA Address JIMMA TOWN/0911911209/ E-Mail ... ashenafihabtamu13@yahoo.com 2. Educational Background S.No Educational Background 1 Primary and junior secondary school School Name Wollega Adventist Academy(WAA) Year 1986-1993E.C Location Dongoro, Ethiopia Mobile: 0910157156

2 3 4

Secondary school education Higher education Higher education

Gimbi high School University Gonder Jimma university

1994-1997E.C 1998-2000E.C 2003-2004E.C

Gimbi, Ethiopia Gonder, Ethiopia Jimma Ethiopia

4. QUALIFICATION MPH/HEALTH E ECONOMIST

3. RESARCH ACTIVITPerception and practice of Emergency contraception Among Female

5. SERVICE EXPERIENCE3years of work experiences as HIV/AIDS expert in Zonal Health Department.

6. SKILComputer Literacy 7. Reference

CURIULUM VITAE 1. PERSONAL BACKGROUND Name Mustefa Geleto Sex..Male Date of birth..1988 G.C Marital statussingle Nationality Ethiopia Address ..Jimma town/0912291716/ E-mail.geletom@yahoo.com

2. Educational Background S.No Educational Background 1 Primary and junior secondary School Name Dodola Primary Year 1988-1993E.C Location Dodola Ethiopia

school 2 Secondary school education

school Dodola Secondary school 1994-1997E.C Dodola Ethiopia

3 4

Higher education Higher education

Gonder Univertsity 1998-2000 E.C Jimma University 2003-2004E.C

Gonder Ethiopia Jimma, Ethiopia

4. QUALIFICATION MPH/EPIDEMIOLOGIST

3. RESARCH ACTIVITY KAP on modern contraception

5. SERVICE PERIENCE3 years of work experiences as planner in zonal health office 6. SKILL Diploma in computer from Cisco Network academy 7. Reference Ahmad Nasir(Zonal Health Department Head) Address: 0911076287 CURIULUM VITAE 1.PERSONALBACKGROUND Name..Gebeyehu Tsega Sex..Male Date of birth..1988 G.C Marital status..Single NationalityEthiopian Address .Jimma town /0921332083/ E-Mailgebishts@gmail.com S.No Educational Background 1 Primary and junior secondary school 2 Secondary and preparatory School Name Debelima Primary School Tewdros II 1996-1999 E.C Year 1987-1995E.C Location Debretabor, Ethiopia Debretabor,

school education Higher education

Secondary school Arbaminch University 2000-2002 E.C

Ethiopia Arbaminch, Ethiopia 2003-2004E.C Jimma Ethiopia

Higher education

Jimma University

2. Educational Background 4. QUALIFICATION MPH/ COMMNICATION SPECIALIST 3. RESARCH ACTIVITYprevalence of contraceptive use among female of Serbo residents Assessment of health service coverage in Sigmo wereda 5. SERVICE EXPERIENCE 2 years as instructor in Jimma University 6. SKILL Basic computer 7. REFERNCE Bahailu Medrekiwos, Head of Arbaminch University, Collage of Public Health and Medical Sciences Address 0910809022

CURIULUM VITAE 1.PERSONAL BACKGROUND Name: Melaku Haile Sex... male Date of birth 1976 E.C Marital statussingle Nationality ... Ethiopia Address 0913282151 E-Mail .mhaile67@yahoo.com

2. Educational Background S.No Educational Background 1 Primary and junior secondary school 2 Secondary school education Nefas silk high school 3 Higher education Hawassa University Higher education 4. QUALIFICATION Bsc ,MSC Biostatistics 3.RESARCH ACTIVITY Process evaluation on PMTCT at Jimma zone in 2003 E.C 5. EXPERIENCE 2 years in Health Center as laboratory technologist 2 years as Instructor in Health Sciences College 6. SKIL Jimma university 2002-2003 E.C Jimma,Ethiopia 1995-1998 E.C 1990-1994 E.C School Name Frehiwot No 2 Year 1983-1989 E.C Location Addis Ababa, Ethiopia Addis Ababa, Ethiopia Hawassa, Ethiopia

Computer Litracy 7. Reference Nigussie Beyene Adress 0912286269

Logical framework
Vertical hierarchy of objective Objectively verifiable indicators (OVI) Means of verification Impact assessment Assumption

Goal:
To Improve Skilled Delivery in four woredas of Jimma zone

Reduced maternal mortality ratio related to pregnancy by 10%

Purpose
To supply delivery kit for all Health facilities in four woredas of Jimma Zone. To Provide training for 2 health workers per Health center on skilled delivery Increase Community awareness on benefit of skilled delivery To Strengthen referral system between Health centers and Hospital

Number of health facilities supplied 100% with delivery kit within five years 2 trained health professionals on delivery in each facility within five years Number of community conversations conducted within five years Number of pregnant women delivered by trained health professionals by 2017

Record of monthly report. Quarterly evaluation report. Facility report Training record supply record and report

There are properly functioning health care facilities in each projected woredas Strong community participation and staff commitment

Output
Number of health facilities supplied with delivery kits Number of health facilities with

20 Training sessions are conducted. 160 health professionals are trained 192 HEW are trained 960 CHW are trained 115,816 pregnant mothers attended by

Record of monthly report. Quarterly evaluation report. Facility report Training

Shortage of delivery kits in each projected woredas of health facilities Strong community involvement

at least two health professionals trained on safe and clean delivery. Number Of Households participated on panel discussion and community conversation Number of pregnant women attending Health Facilities for skilled delivery

trained professionals All necessary kits distributed to selected health facilities

record supply record and report

Activity Conducting baseline survey for identification of scarcity of delivery kit Signing with PSI Ethiopia for procurement and distribution of kits to health facilities Procuring ambulances for each projected Woredas Developing training manual for health workers

4 ambulance bought and distributed to each projected Woredas Number of training manuals developed 20 training sessions conducted 4 referral guides provided to health care facilities (No of Keb *12)*5 Community conversations conducted

supply record and report Record of monthly report. Training records Records of community conversation team

Getting permission from internal tax and revenue authority to procure the Equipment and supplies tax free. Availability of resoures

 Providing intensive practical based training on safe and clean delivery Provision of TOT for community leaders, Model Households and respected individuals in the community on benefits of skilled delivery Developing and conducting community conversation on advantage of skilled delivery, especially focusing on the risk of not utilizing skilled delivery services Providing referral guideline for all Health facilities

Letter for Funding

Date 20/05/2012 Name of Organization Improving Skilled Delivery Problem Address City: Jimma Town Dear Thank you for the opportunity to be considered for support by the IDRC In the three short years since its founding, the Improving Skilled Delivery Problem project has played a major role in reducing skilled delivery problem that lead to morbidity and mortality of mothers, in the four woredas (Tiro-afata, keresa. Gomma, and manna) Improving Skilled Delivery Problem has a total of 32 staff and other stakeholders works together for the accomplishment of the project goal and objectives. The Improving Skilled Delivery Problem project is requesting $ 4,684,087.10 from the IDRC to support this program that makes a meaningful difference in the lives of mothers. We believe that the Improving Skilled Delivery project is consistent with the Mission and interest of Ethiopian health policy, and hope that you will find it in your hearts and budget to support this program. If I can provide additional information to encourage consideration of our request, please feel free to contact me at tes.da08@yahoo.com/ ashenafihabtamu13@yahoo.com I would also be happy to personally meet with your committee to present this proposal. Sincerely yours Tesfaye Dagne Head, Jimma Zone Health Departement