Presentation by Alimou Barry, Janine Barden-O’Fallon, Jack Hazerjian, and Paul Brodish.

1. Alimou Barry, Janine Barden-O’Fallon,
Jack Hazerjian, Paul Brodish
MEASURE Evaluation
24 June 2015
A Rapid Assessment
of Ebola-Related
Implications for
RMNCH Service
Delivery and
Utilization in
Guinea

2. WEEKLY INCIDENCE of CONFIRMED CASES of
EBOLA in GUINEA
Rapid assessment data collection period
http://apps.who.int/ebola/current-situation/ebola-situation-report-10-june-2015
0
20
40
60
80
100
120
140
160
180
Confirmed
Ebola Cases per
Week From
Start of 2015
Confirmed
Ebola Cases per
Week through
End of 2014
171

3. CASES of EBOLA in GUINEA
Cumulative Number
of Confirmed Cases
by Age Group‡
(per 100,000 population)
0-14 years 15-44 years 45+ years
Through
10 June, 2015
505
(11)
1846
(40)
838
(54)
Population figures are based on estimates from the United Nations Department of Economic and Social Affairs
‡Excludes cases for which data on age are not available.
From: http://apps.who.int/ebola/current-situation/ebola-situation-report-10-june-2015
Disproportionally affected adults and individuals in certain regions of the country

4. DEATHS from EBOLA in GUINEA
Cumulative Number
of Confirmed Deaths
in Total Population
(case fatality rate)
among Health Care Workers
(case fatality rate)
Through
10 June, 2015
2018
(62.3%)
94
(50.3%)
Population figures are based on estimates from the United Nations Department of Economic and Social Affairs
From: http://apps.who.int/ebola/current-situation/ebola-situation-report-10-june-2015

5. INDIRECT EFFECTS of EBOLA
 Reports of clinic closures, patients being turned
away from services, and patients avoiding health
facilities out of fear
o In Sierra Leone, median inpatient admissions
dropped 70% between May and October 2014
• Reports of suspension of services, such as
vaccinations
To what extent are routine RMNCH services
in Guinea affected by Ebola?

6. OBJECTIVE
ASSESS DELIVERY
AND UTILIZATION OF
ROUTINE
RMNCH SERVICES IN
SELECTED FACILITIES
ACROSS GUINEA

7. METHODS
 Compile and analyze facility data on key routine
RMNCH services from October 2013 (pre-Ebola)
through December 2014
 Conduct interviews with:
o directors of health districts
o directors of health facilities
o providers of RMNCH services
o traditional practitioners
 Use convenience sample of government and
private clinics in locations throughout Guinea with
variable Ebola incidence
Koulewondy Health
Center, Conakry

8. MAP of CONAKRY and 12 PRÉFECTURES
SELECTED for the STUDY

9. SELECTED STUDY SITES CLASSIFIED‡ AS
« ACTIVE », « CHANGING STATUS», or « INACTIVE >>
ACTIVE
(throughout)
CHANGING
STATUS
INACTIVE
(throughout)
GUÈCKÈDOU
CONAKRY CITY
DISTRICTS:
DIXINN
MATAM
RATOMA
BOFA
COYAH
DABOLA
DALABA
FARANAH
FRIA
KISSIDOUGOU
N’ZÈRÈKORÈ
SIGUIRI
MAMOU
MANDIANA
13 FACILITIES 26 FACILITIES 6 FACILITIES
‡ Based on retrospective review of Ebola case incidence for the period March-December 2014

10. KEY RMNCH INDICATORS
REPRODUCTIVE HEALTH
o New and continuing accepters of modern contraceptive methods
o Months with incidence of stockouts of contraceptive pills,
injectables, and/or condoms
Health education
mural at Guèckèdou
Prefectoral Hospital

11. MATERNAL HEALTH
o Pregnant women tested for HIV
o Pregnant women seen at first and third
prenatal visits
o Cases of pregnancy complications
o Facility-based births
o Maternal deaths
o Outpatient services
Horoya Health Center,
N’Zèrèkorè
KEY RMNCH INDICATORS

12. CHILD HEALTH
o Children vaccinated with Penta 1 and
Penta 3
o Children under 5 years of age with acute
respiratory illness, moderate malnutrition,
and diarrhea
o Child outpatient services
o Months with incidence of stockouts of
oral rehydration salts and Cotrimoxazole
o Children under 5 years of age hospitalized
due to acute respiratory illness Pediatric Ward of
Guèckèdou Prefectoral
Hospital
KEY RMNCH INDICATORS

13. DATA COLLECTION INSTRUMENTS

14. Questionnaire for Directors of Health Services at Health District
o (Ex: facility closings; staffing issues; Ebola training; reporting continuity)
Questionnaire for Directors of Health Facilities
o (Ex: Ebola triage and referral; Ebola risk management; medical stockouts; medical
and personal concerns related to Ebola; recommendations)
Questionnaire for Providers of RMNCH Services
o (Ex: service suspension; Ebola training; Ebola risk management; medical
complications; Ebola-related concerns; recommendations)
Questionnaire for Traditional Practitioners
o (Ex: changes in service delivery and procedures; Ebola risk management)
DATA COLLECTION INSTRUMENTS

15. ETHICAL CONSIDERATIONS
 Informed consent received from all interviewees
 No identifying information collected from respondents
 No personally sensitive questions asked about health status
 Exemption received from University of North Carolina’s Ethics
Committee and Guinea’s Ministry of Health

16. LOGISTICS and COORDINATION
 Collaborated with StatView International for
data collection and data entry
 Coordinated with Ministry of Health Office of
Strategic Development and Family Health
Department
 Communicated with directors of health services
at each study site, before and during field work,
with request to have a designated official work
along field study team

17. DATA QUALITY CONSIDERATIONS
 Six data collection teams, each with a
physician as lead
 Three quality monitoring teams to
ensure that protocols and practices
were being observed and that forms
were completed correctly
 Data inscription into Epi 7 checked
against the field study forms

18. TIME LINE
2015 DATES
12 January
19 – 24 January
25 – 27 January
28 January – 8 February
9 – 17 February
18 February
19 February – 28 April
29 April
30 April – 13 May
30 May
24 June
• ACTIVITIES
• Approval of protocols and instruments
• Training of field workers and data clerks
• Coordination meetings w/ Ministry of Health and Public Hygiene
• UNC Ethics Committee approval
• Data collection
• Data entry and quality checks
• Debriefing with USAID/Guinea on preliminary findings
• Data cleaning, data analysis and preparation of report
• Submission of draft report to USAID/Guinea
• Review and finalization of report
• Submission of final report in English and French translation
• Presentation to USAID/Guinea

19. FACILITY DATA

20. OUTPATIENT SERVICES
Macire Health Center,
Dixinn Commune, Conakry

21. COMPARISON‡
of MEDIAN NUMBER of OUTPATIENT SERVCES in
OCT-DEC 2013 and 2014 from 45 FACILITIES
Oct-Dec
2013
Oct-Dec
2014
% Change
** p<.01
Outpatients (adults and children)
Hospitals 1355 930 – 31**
Health Centers 1223 1147 – 6**
Pediatric Outpatient Ward,
Donka National Hospital,
Conakry
Gonia Market
Health Center,
N’Zèrèkorè
‡ Wilcoxon signed rank test with median values
of services provided in each of the 2 quarters

22. FINDINGS by EBOLA ZONE
OUTPATIENT SERVICES
0
500
1000
1500
2000
2500
1 2 3 4 5
Time (quarters)
changing active
inactive
Median
number of
outpatient
visits
at hospitals
HOSPITALS
• Median number of adult and child outpatients:
 significantly declined across all Ebola status zones
 increased in early 2014 in Ebola active zone before steady
decline thereafter
 relatively flat in inactive and changing Ebola status zones
before large declines late in 2014

23. FINDINGS by EBOLA ZONE
OUTPATIENT SERVICES
Median
number of
outpatient
visits
at health
centers 0
1000
2000
3000
1 2 3 4 5
Time (quarters)
changing active
inactive
HEALTH CENTERS
• Median number of adult and child outpatients:
 small decline across all Ebola status zones
 increased Apr-Jun 2014 in Ebola active zone before steady
decline thereafter
 gradual increases in inactive and changing Ebola status zones
before small declines in Oct-Dec 2014

24. REPRODUCTIVE HEALTH
Ratoma Communal Health Center,
Ratoma Commune, Conakry

25. COMPARISON‡
of MEDIAN NUMBER of SERVCES and STOCKOUTS
of MODERN CONTRACEPTIVES OCT-DEC 2013 and 2014
from 45 FACILITIES
Oct-Dec
2013
Oct-Dec
2014
% Change
New Acceptors: Modern Contraception
Hospitals 19 12 – 37
Health Centers 25 34 + 36
Continuing Acceptors: Modern Contraception
Hospitals 60 50 – 17
Health Centers 26 28 + 8
Number of Facilities
Reporting Stockout
Stockouts of Key Contraceptives
over
15-Month
Period
over
9-Month
Period
of Ebola
Injectables 10 3
Oral Contraceptive Pills 7 2
Condoms 11 2
‡ Wilcoxon signed rank test with median values
of services provided in each of the 2 quarters

26. MATERNAL HEALTH
Hafia Health Center,
Dixinn Commune, Conakry

27. COMPARISON‡
of MEDIAN NUMBER of SERVICES in
OCT-DEC 2013 and 2014 from 45 FACILITIES
Oct-Dec
2013
Oct-Dec
2014
% Change
* p<.05
Pregnant Women Tested for HIV
Hospitals 112 55 – 51*
Health Centers 255 246 – 4
Pregnancy Complications
Hospitals 10 8 – 20
Pregnant Women Seen for ANC 1
Health Centers 337 295 – 12
Pregnant Women Seen for ANC 3
Health Centers 245 205 – 16
Facility-Based Births
Hospitals 303 281 – 7
Health Centers 100 69 – 31
‡ Wilcoxon signed rank test with median values
of services provided in each of the 2 quarters

28. FINDINGS by EBOLA ZONE
MATERNAL HEALTH SERVICES
0
100
200
300
1 2 3 4 5
Time (quarters)
changing active
inactive
Median number of pregnant
women tested for HIV in hospitals
• Only HIV testing of pregnant
women at hospitals showed a
statistically significant decline
• Drop in HIV testing at hospitals in
Ebola active zone heavily
accounts for overall decline

29. CHILD HEALTH
Children Playing in Football Stadium,
N’Zèrèkorè

30. COMPARISON‡
of MEDIAN NUMBER of SERVICES in
OCT-DEC 2013 and 2014 from 45 FACILITIES
Oct-Dec
2013
Oct-Dec
2014
% Change
* p<.05
** p<.01
PENTA 1 Vaccinations Given
Hospitals 504 316 – 37
Health Centers 259 212 – 18**
PENTA 3 Vaccinations Given
Hospitals 353 320 – 9
Health Centers 244 167 – 32**
Watery/Bloody Diarrhea, Child < 5 Yrs of Age
Hospitals 34 14 – 59**
Health Centers 16 12 – 25**
Acute Respiratory Illness (ARI), Child < 5 Yrs
Hospitals 98 41 – 58**
Health Centers 108 83 – 23**
Hospitalization due to ARI, Child < 5 Yrs
Hospitals 18 16 – 11
‡ Wilcoxon signed rank test with median values
of services provided in each of the 2 quarters

31. Median number
of Penta 1
vaccinations
given at
health centers
FINDINGS by EBOLA ZONE
CHILD HEALTH SERVICES – PENTA VACCINATIONS
0
100
200
300
400
500
1 2 3 4 5
Time (quarters)
changing active
inactive
Median number
of Penta 3
vaccinations
given at health
centers
0
100
200
300
400
1 2 3 4 5
Time (quarters)
changing active
inactive
• Throughout all Ebola status
zones, significant declines in
vaccinations given at health
centers -- but not at hospitals
• Yet declines not constant:
 Declining Pentavalent 1
vaccinations show some
increases during last quarter
of 2014
 Pentavalent 3 vaccinations
started falling as Ebola
cases grew in detection,
especially in Ebola active
zone

32. Median number
of cases of
diarrhea in
children under
five years of
age
in hospitals
FINDINGS by EBOLA ZONE
CHILD HEALTH SERVICES –DIARRHEA
Median number
of cases of
diarrhea in
children under
five years of
age
in health
centers
0
50
100
150
1 2 3 4 5
Time (quarters)
changing active
inactive
0
50
100
150
1 2 3 4 5
Time (quarters)
changing active
inactive
• Cases of diarrhea in children
< 5 years significantly
decreased across all Ebola
status zones
• Declines were not constant
throughout 2014

33. Median
number of
cases of ARI
in children
under five
years of age
treated at
hospitals
FINDINGS by EBOLA ZONE
CHILD HEALTH SERVICES – TREATMENT of ARI
0
100
200
300
400
1 2 3 4 5
Time (quarters)
changing active
inactive
HOSPITALS
• Median number of children < 5 with ARI:
 significantly decreased across all Ebola status zones
 declines not constant in Ebola changing status zones
 slight increase in final quarter of 2014 in Ebola active zone

34. Median
number of
cases of ARI
in children
under five
years of age
treated at
health centers 0
100
200
300
400
1 2 3 4 5
Time (quarters)
changing active
inactive
HEALTH CENTERS
• Median number of children <5 with ARI:
 trended upwards in early 2014 in Ebola active and inactive zones
before declining
 steepest declines are in final quarter of 2014 for Ebola inactive and
changing status zones
FINDINGS by EBOLA ZONE
CHILD HEALTH SERVICES – TREATMENT of ARI

35. Number of Facilities
Reporting Stockout‡
Stockouts of Key Child Medications
over
15-Month
Period
over
9-Month
Period
of Ebola
Oral Rehydration Salts 22 8
Cotrimoxazole (Antibiotic) 18 9
STOCKOUTS of 2 KEY MEDICATIONS
in 45 FACILITIES
‡Due to the small number of facilities reporting stockouts of key child medications and contraceptives, this
information was reported by total number recorded for the 15‐month period, and the number recorded only
after the start of the Ebola outbreak (April through December 2014)

36. INTERVIEW DATA
MANAGERS / DIRECTORS of HEALTH FACILITIES
Health Center of Horoya, N’Zèrèkorè

37. %
Public
Facilities
N = 43*
%
Private
Facilities
N = 19
Chi-Square
Test
Results
Facility reduced hours due to Ebola crisis 5 32 p < 0.01
Facility suspended services due to Ebola concerns 7 26 p < 0.05
Manager / Director noticed increase in complications
among patients who delayed accessing
health services during Ebola crisis
28 0 p < 0.01
Director reported service providers at the facility have
received training on Ebola infection control
93 68 p < 0.05
Director feels community members have concerns about
the safety of services at the facility
84 58 p < 0.05
Facility has been able to maintain routine data collection
and reporting as usual during Ebola crisis
98 74** p < 0.01
DIRECTORS of HEALTH FACILITIES (n = 62)
SIGNIFICANT DIFFERENCES‡ BY PUBLIC AND PRIVATE FACILITY
‡Chi-square test for equivalency was used
*While data was collected at a total of 45 public facilities, interviews with heads of such facilities could only be collected at
43 of them
**Percent for routine data collection only; reporting of health services data by private health care facilities not studied

38. RMNCH Providers (n = 117)
Views on Health Delivery Services and Use
o 28% cited increase in
complications
o 86% cited changes in use of
health services by those in
the community
o 96% reported to have
changed their own practices
in providing maternal and
child health services
o 97% reported regular wearing
gloves when offering services
o 70% received training in
Ebola prevention
Staff Bulletin Board, N’Zèrèkorè Hospital

39. o 63% cited concerns about
Ebola held by those in their
community
o 36% cited negative
reactions from family
members and friends about
Ebola
o 80% reported concerns
about their security when
offering health services
o 7% reported that health
services at their health
facility had been suspended
or stopped due to Ebola Ebola Treatment Center,
Donka National Hospital, Conakry
RMNCH Providers (n = 117)
Views on Health Delivery Services and Use

40. Significant Negative Findings
o Overall decline in services, found more greatly at hospitals than
at other facilities
o Child health services most affected by Ebola
 especially vaccinations that require multiple visits, diarrhea
and ARI cases
 possibly due to parental reluctance to visit a health facility
o Significant decline reported by hospitals of HIV testing of
pregnant women
o Stockouts of some basic medicines have continued to be an
ongoing concern
o One‐third of health care providers received no training in Ebola
infection control
o A sizeable percentage of interviewees felt that their position as
health care providers is stigmatized by those in their community
Summary Conclusions

41. Significant Positive Findings
o Despite Ebola, information system on routine health services
continued to function
o Ebola does not appear to have had a widespread negative
impact on the availability of health services
o Many improved infection control measures have been adopted,
including routine hand washing by both health care workers and
traditional healers
Summary Conclusions

42. FIELD STUDY TEAMS

43. QUESTIONS? COMMENTS?

44. THANK YOU !

45. ACKNOWLEDGEMENTS
We are deeply grateful to USAID/Guinea and the Ministry of Health and Public
Hygiene for their support and commitment to this rapid assessment
In particular, we would like to cite the valuable assistance provided by:
Dr. Younoussa Ballo, Secretary General, Ministry of Health and Public Hygiene
Dr. Sekou Condé, Deputy Coordinator of the Fight against Ebola
Dr. Mamady Kourouma, the Director of Family Health and Nutrition
Dr. Boubacar Sall, Acting Director, Office of Strategy and Development
We also acknowledge the meaningful support and cooperation of the dedicated
professionals we met in the field, most notably, all health staff at the Regional
Health Directorate and District Health Offices and the dedicated staff at the
hospitals, health centers, and clinics we visited in Conakry and the 12
prefectures
Finally, we give our sincere thanks to StatView International for recruiting
excellent data collectors and providing tremendous logistical support to the field
work, without which this rapid assessment would not have been completed so
promptly

46. MEASURE Evaluation is funded by the U.S. Agency
for International Development (USAID) under terms
of Cooperative Agreement AID-OAA-L-14-00004
and implemented by the Carolina Population Center,
University of North Carolina at Chapel Hill in
partnership with Futures Group, ICF International,
John Snow, Inc., Management Sciences for Health,
and Tulane University. The views expressed in this
presentation do not necessarily reflect the views of
USAID or the United States government.
www.measureevaluation.org