Browsing by Author "Sanders, David"
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Item Addressing social determinants of health in South Africa: the journey continues(Health Systems Trust (HST), 2017) Scott, Vera; Schaay, Nikki; Schneider, Helen; Sanders, DavidWith the recent change from the Millennium Development Goals to the 17 new Sustainable Development Goals, the focus of the global development agenda is expanding: there is attention on a broader set of social determinants and, importantly, a specific sensitivity to equity, which could have a substantial effect on health. Addressing social determinants is a cornerstone in the National Department of Health’s Primary Health Care Re-engineering Strategy, and an approach that is embedded in the country’s National Development Plan. However, the translation of this policy commitment to programmatic action at different levels in the health system and in partnership with other sectors remains elusive.Item Addressing the tensions and complexities involved in commissioning and undertaking implementation research in low- and middle-income countries(BMJ, 2018) Doherty, Tanya; Lewin, Simon; Kinney, Mary; Sanders, David; Mathews, Cathy; Daviaud, Emmanuelle; Goga, Ameena; Bhana, Arvin; Besada, Donela; Vanleeuw, Lieve; Loveday, Marian; Odendaal, Willem; Leon, NatalieRapid scale-up of new policies and guidelines, in the context of weak health systems in low/middle-income countries (LMIC), has led to greater interest and funding for implementation research. Implementation research in LMICs is often commissioned by institutions from high-income countries but increasingly undertaken by LMIC-based research institutions. Commissioned implementation research to evaluate large-scale, donor-funded health interventions in LMICs may hold tensions with respect to the interests of the researchers, the commissioning agency, implementers and the country government. We propose key questions that could help researchers navigate and minimise the potential conflicts of commissioned implementation research in an LMIC setting.Item Advancing the agenda on noncommunicable diseases: prevention and management at community level(Health Systems Trust (HST), 2017) Puoane, Thandi; Egbujie, Bonaventure Amandi; Sanders, David; Tsolekile, Lungiswa Primrose; Lewy, MarcSouth Africa is experiencing an increase in the prevalence of non-communicable diseases (NCDs), which imposes a heavy burden on healthcare services. The South African government has made great strides towards management and control of NCDs, including the development of management guidelines, healthpromotion and prevention policies intended to assist healthcare workers, facilities and communities in NCD care. However, it appears that the facility-based component of NCD management and control efforts has received more attention than the community-level components. The national strategic plan for NCDs highlights the importance of community-level interventions in chronic NCD care. Thus there is a need for community-based strategies for NCD prevention, control and management to complement facility-based health services. This chapter explores the advancement of the NCD agenda in South Africa through an emphasis on community-level prevention and management. It describes interventions that used community actors such as community health workers in NCD care. The chapter discusses some of the challenges of these interventions, and ends with possible suggestions for South Africa.Item Allergy and infant feeding guidelines in the context of resource-constrained settings(American Academy of Allergy, Asthma and Immunology, 2016) Levin, Michael; Goga, Ameena; Doherty, Tanya; Coovadia, Hoosen; Sanders, David; Green, Robin J.; Kling, SharonRecent discussions about the need for revised infant feeding guidelines in the context of allergy are founded in substantial evidence-based research. Key studies (Table I)1-5 undertaken in high-income country settings provide evidence that the introduction of allergenic foods (eg, cow’s milk protein, egg, peanuts, fish, sesame, and wheat) to infant diets before the age of 6 months might significantly reduce the risk of food allergy at older ages. Although such a strategy does not promote supplanting breastfeeding with the introduction of a diverse set of foods early on, it will shorten the duration of exclusive breast-feeding [EBF], replacing it with ‘‘partial breast-feeding,’’ the combination of breast-feeding with other fluids or solids, and most likely lead to a reduction in overall duration of breast-feeding.Item Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM AND Pepfar-funded HIV-activities(BioMed Central -The Open Access Publisher, 2013) Cailhol, Johann; Craveiro, Isabel; Mathole, Thubelihle; Parsons, Ann Neo; Lehmann, Uta; Sanders, David; Madede, Tavares; Makoa, Elsie; Van Leemput, Luc; Biesma, Regien; Brugha, Ruairi; Chilundo, Baltazar; Dussault, Gilles; Van Damme, WimBACKGROUND: Global Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined. METHODS: A multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries’ responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context. RESULTS: In all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs. CONCLUSION: Sustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.Item Approaches and strategies used in the training and supervision of Health Extension Workers (HEWs) delivering integrated community case management (iCCM) of childhood illness in Ethiopia: a qualitative rapid appraisal(Makerere University Medical School (Uganda), 2018) Nsibande, Duduzile; Loveday, Marian; Daniels, Karen; Sanders, David; Doherty, Tanya; Zembe, WangaBACKGROUND: Globally, preventable and treatable childhood conditions such as pneumonia, diarrhoea, malaria, malnutrition and newborn conditions still account for 75% of under-five mortality. To reduce the mortality rate from these conditions, Ethiopia launched an ambitious Health Extension Programme (HEP) in 2003. Trained Community Health Workers (CHWs), named Health Extension Workers (HEWs) were deployed to deliver a package of care which includes integrated Community Case-Management (iCCM) of common childhood diseases. OBJECTIVES: This qualitative study aimed to explore approaches and strategies used in the HEW training and supervision as part of an evaluation of the Catalytic Initiative to Save a Million Lives. METHODS: A qualitative rapid appraisal study using focus group discussions and in-depth interviews was conducted. RESULTS: Training of HEWs followed a cascaded training of trainer approach supported by implementing partners under guidance of the Ministry of Health. A comprehensive planning phase enabled good coverage of districts and consistency in training approaches. Training was complemented by on-going supportive supervision. HEW motivation was enhanced through regular review meetings and opportunities for career progression. CONCLUSION: These findings describe a thorough approach to training and supervision of HEWs delivering iCCM in rural Ethiopia. Ongoing investments by partners will be critical for long-term sustainability.Item Assessing the health impact of transnational corporations: its importance and a framework(BioMed Central, 2016) Baum, Fran; Sanders, David; Fisher, Matt; Anaf, Julia; Freudenberg, Nicholas; Friel, S.; Labonte, Ronald; London, Leslie; Monteiro, Carlos; Scott-Samuel, Alex; Sen, AmitBACKGROUND: The adverse health and equity impacts of transnational corporations' (TNCs) practices have become central public health concerns as TNCs increasingly dominate global trade and investment and shape national economies. Despite this, methodologies have been lacking with which to study the health equity impacts of individual corporations and thus to inform actions to mitigate or reverse negative and increase positive impacts. METHODS: This paper reports on a framework designed to conduct corporate health impact assessment (CHIA), developed at a meeting held at the Rockefeller Foundation Bellagio Center in May 2015. RESULTS: On the basis of the deliberations at the meeting it was recommended that the CHIA should be based on ex post assessment and follow the standard HIA steps of screening, scoping, identification, assessment, decision-making and recommendations. A framework to conduct the CHIA was developed and designed to be applied to a TNC's practices internationally, and within countries to enable comparison of practices and health impacts in different settings. The meeting participants proposed that impacts should be assessed according to the TNC's global and national operating context; its organisational structure, political and business practices (including the type, distribution and marketing of its products); and workforce and working conditions, social factors, the environment, consumption patterns, and economic conditions within countries. CONCLUSION: We anticipate that the results of the CHIA will be used by civil society for capacity building and advocacy purposes, by governments to inform regulatory decision-making, and by TNCs to lessen their negative health impacts on health and fulfil commitments made to corporate social responsibility.Item Assessment of the uptake of neonatal and young infant referrals by community health workers to public health facilities in an urban informal settlement, KwaZulu-Natal, South Africa(Biomed Central, 2013) Nsibande, Duduzile; Doherty, Tanya; Ijumba, Petrida; Tomlinson, Mark; Jackson, Debra; Sanders, David; Lawn, JoyBackground: Globally, 40% of the 7.6 million deaths of children under five every year occur in the neonatal period (first 28 days after birth). Increased and earlier recognition of illness facilitated by community health workers (CHWs), coupled with effective referral systems can result in better child health outcomes. This model has not been tested in a peri-urban poor setting in Africa, or in a high HIV context. Methods: The Good Start Saving Newborn Lives (SNL) study (ISRCTN41046462) conducted in Umlazi, KwaZulu- Natal, was a community randomized trial to assess the effect of an integrated home visit package delivered to mothers by CHWs during pregnancy and post-delivery on uptake of PMTCT interventions and appropriate newborn care practices. CHWs were trained to refer babies with illnesses or identified danger signs. The aim of this sub-study was to assess the effectiveness of this referral system by describing CHW referral completion rates as well as mothers’ health-care seeking practices. Interviews were conducted using a structured questionnaire with all mothers whose babies had been referred by a CHW since the start of the SNL trial. Descriptive analysis was conducted to describe referral completion and health seeking behaviour of mothers. Results: Of the 2423 women enrolled in the SNL study, 148 sick infants were referred between June 2008 and June 2010. 62% of referrals occurred during the first 4 weeks of life and 22% between birth and 2 weeks of age. Almost all mothers (95%) completed the referral as advised by CHWs. Difficulty breathing, rash and redness/discharge around the cord accounted for the highest number of referrals (26%, 19% and 17% respectively). Only16% of health workers gave written feedback on the outcome of the referral to the referring CHW. Conclusions: We found high compliance with CHW referral of sick babies in an urban South African township. This suggests that CHWs can play a significant role, within community outreach teams, to improve newborn health and reduce child mortality. This supports the current primary health care re-engineering process being undertaken by the South African National Department of Health which involves the establishment of family health worker teams including CHWs.Item "Big Food", the consumer food environment, health and the policy response in South Africa(Public Library of Science, 2012) Igumbor, Ehimario U.; Sanders, David; Puoane, Thandi; Tsolekile, Lungiswa; Schwarz, Cassandra; Purdy, Christopher; Swart, Rina; Durao, Solange; Hawkes, CorinnaSummary Points: * In South Africa, as in other jurisdictions, ‘‘Big Food’’ (large commercial entities that dominate the food and beverage environment) is becoming more widespread and is implicated in unhealthy eating. * ‘‘Small food’’ remains significant in the food environment in South Africa, and it is both linked with, and threatened by, Big Food. * Big Food in South Africa involves South African companies, some of which have invested in other (mainly, but not only, African) nations, as well as companies headquartered in North America and Europe. * These companies have developed strategies to increase the availability, affordability, and acceptability of their foods in South Africa; they have also developed a range of ‘‘health and wellness’’ initiatives. Whether these initiatives have had a net positive or net negative impact is not clear. The South African government should act urgently to mitigate the adverse health effects in the food environment in South Africa through education about the health risks of unhealthy diets, regulation of Big Food, and support for healthy foods.Item Building capacity to develop an African teaching platform on health workforce development: a collaborative initiative of universities from four sub Saharan countries(BioMed Central, 2014) Amde, Woldekidan Kifle; Sanders, David; Lehmann, UtaINTRODUCTION: Health systems in many low-income countries remain fragile, and the record of human resource planning and management in Ministries of Health very uneven. Public health training institutions face the dual challenge of building human resources capacity in ministries and health services while alleviating and improving their own capacity constraints. This paper reports on an initiative aimed at addressing this dual challenge through the development and implementation of a joint Masters in Public Health (MPH) programme with a focus on health workforce development by four academic institutions from East and Southern Africa and the building of a joint teaching platform. METHODS: Data were obtained through interviews and group discussions with stakeholders, direct and participant observations, and reviews of publications and project documents. Data were analysed using thematic analysis. CASE DESCRIPTION: The institutions developed and collaboratively implemented a ‘Masters Degree programme with a focus on health workforce development’. It was geared towards strengthening the leadership capacity of Health ministries to develop expertise in health human resources (HRH) planning and management, and simultaneously build capacity of faculty in curriculum development and innovative educational practices to teach health workforce development. The initiative was configured to facilitate sharing of experience and resources. DISCUSSION: The implementation of this initiative has been complex, straddling multiple and changing contexts, actors and agendas. Some of these are common to postgraduate programmes with working learners, while others are unique to this particular partnership, such as weak institutional capacity to champion and embed new programmes and approaches to teaching. CONCLUSIONS: The partnership, despite significant inherent challenges, has potential for providing real opportunities for building the field and community of practice, and strengthening the staff and organizational capacity of participant institutions. Key learning points of the paper are: *the need for long-term strategies and engagement; *the need for more investment and attention to developing the capacity of academic institutions; *the need to invest specifically in educational/teaching expertise for innovative approaches to teaching and capacity development more broadly; and *the importance of increasing access and support for students who are working adults in public health institutions throughout Africa.Item Can a new paediatric sub-specialty improve child health in South Africa?(Health & Medical Publishing Group, 2012) Swingler, George; Hendricks, Michael; Hall, David; Hall, Susan; Sanders, David; McKerrow, Neil; Saloojee, Haroon; Reid, SteveCompared with other middle-income countries, child health in South Africa is in a poor state, and should be addressed by focusing on the healthcare needs of all children across a system or region. Paediatricians have had little effect on this situation, partly because their training is not aligned with South African needs. The proposed re-engineering of primary healthcare will be limited by the skewed distribution of staff and the lack of suitable skills. A 'community' placement during specialist training, and the creation of a sub-specialty in Community Paediatrics and Child Health, could address the skills shortage and possibly attract health personnel to under-served areas through creating an appropriate career path. This proposal would also support the Department of Health's encouraging plans to re-engineer primary healthcare.Item Capacity-building for a strong public health nutrition workforce in lowresource countries(World Health Organization, 2017) Delisle, Hélène; Shrimpton, Roger; Sanders, DavidNeglected for several decades, nutrition is now firmly on the development agenda. Important landmarks are the initiation of the Scaling Up Nutrition movement in 2010; the adoption by the World Health Assembly of the Comprehensive Implementation Plan for Maternal, Infant and Young Child Nutrition in 2014; and the World Health Organization’s (WHO) Global Action Plan for the Prevention and Control of Noncommunicable Diseases for 2013–2020. Public health nutrition has to meet multiple new challenges, including the shift from the millennium development goals to the sustainable development goals (SDGs), together with growing issues such as climate change, globalization, urbanization, socioeconomic disparities, migration and wars.1Item Child mortality in South Africa: Is the Sustainable Development Goal (3.2) target achievable with current efforts?(Health and Medical Publishing Group (HMPG), 2018) Doherty, Tanya; Kroon, Max; Rhoda, Natasha; Sanders, DavidThe two articles by Bamford et al.[1,2] in the recent SAMJ Maternal and Child Health Supplement present trends in inpatient case fatality rates for diarrhoeal disease, pneumonia and severe acute malnutrition (SAM), and a review of under-5 mortality and cause of death using several sources of nationally representative data. While these reviews provide evidence of some improvement, seemingly limited to the impact of prevention of mother-to-child transmission roll-out, we have some comments related to the interpretation of the data.Item Child Support Grant access and receipt among 12-week-old infants in an urban township setting in South Africa(Co-Action Publishing, 2014) Zembe-Mkabile, Wanga; Doherty, Tanya; Sanders, David; Jackson, DebraBACKGROUND: Cash transfers (CTs) are increasingly used as a strategy to alleviate poverty and improve child health outcomes in low- and middle-income countries. The Child Support Grant (CSG) is the largest CT programme in South Africa, and on the continent, targeting poor children from birth until the age of 18 with a monthly sum of R300 (USD30). Evidence on the CSG shows that early receipt of the grant is associated with improved child health outcomes. Since its implementation, one of the major concerns about the grant has been take-up rates, particularly for younger children. This paper reports results on take-up rates for 12-week-old infants residing in an urban township in South Africa. METHODS: This is a descriptive study utilising data from a community-based, cluster-randomised trial which evaluated a programme providing pregnancy and post-natal home visits by community health workers to 3,494 mothers in Umlazi township, South Africa. RESULTS: At the 12-week visit, half (52%) of the mothers who had enrolled in the study had applied for the CSG on behalf of their children, while 85% of the mothers who had not applied were still planning to apply. Only 38% (1,327) of all children had received the CSG. CONCLUSIONS: In this study, many mothers had not applied for the CSG in the first few months after delivery, and only a third of children had accessed the grant. Further research is needed to understand what the current barriers are that prevent mothers from applying for this important form of social protection in the early months after delivery.Item Chronic non-communicable diseases(Health Systems Trust, 2008) Puoane, Thandi; Tsolekile, Lungiswa; Sanders, David; Parker, WhadiahThis chapter will examine the current actions, including lifestyle measures, for the prevention and management of non-communicable diseases within a South African context. It will also focus on the biological, behavioural and social determinants of health. Interventions and initiatives directed at primary, secondary and tertiary prevention of chronic non-communicable diseases are also discussed. This chapter ends with recommended lifestyle changes, which can be taken to influence the adoption of healthy lifestyles, and therefore reduce the risks for chronic non-communicable diseases.Item Commentary: new development goals must focus on social determinants of health(BMJ Publishing Group Ltd, 2013) Legge, David; Sanders, DavidAlthough the millennium development goals (MDGs) addressed some of the starkest manifestations of the contemporary global health crisis, they failed to confront the underlying structures that maintain the crisis, including globalisation. In reflecting on the post-2015 development agenda,1 we need to challenge some key assumptions about the genesis and effect of the current goals.Item Community paediatrics and child health(Health & Medical Publishing Group, 2015) Goga, Ameena; Feucht, Ute; Hendricks, Michael; Westwood, Anthony; Saloojee, Haroon; Swingler, George; McKerrow, Neil; Sanders, DavidTO THE EDITOR: In 2012, the Postgraduate Education Committee of the Health Professions Council of South Africa (HPCSA) supported the accreditation of Community Paediatrics and Child Health (CPCH) as a paediatric subspecialty; however, full HPCSA approval is outstanding. Consequently, by February 2015 there had been no visible progress towards implementation. Power and Heese and Swingler et al. highlighted the benefits of CPCH, rendering further debates about CPCH accreditation unnecessary, particularly in a country where: (i) progress towards the fourth Millennium Development Goal is slow; (ii) glaring gaps exist between hospital-based and community care, and between private and public sector care;[3] and (iii) current under- and postgraduate paediatric training emphasises clinical subspecialties (despite reduced public sector posts), yielding graduates with limited knowledge about priority child health conditions. Primary healthcare re-engineering and the establishment of district clinical specialist teams in South Africa have starkly revealed the urgency of CPCH training. CPCH locates child health within a sociocultural-economic-political-environmental-systemic paradigm. Successful community paediatricians share four characteristics: (i) academic collaboration; (ii) finding evidencebased local solutions; (iii) establishing strong community-based partnerships; and (iv) addressing disease outside traditional biomedical models. This suggests that our sometimes narrow approach to under- and postgraduate training needs significant adaptation. The British Association for Community Child Health, affiliated to the Royal College of Paediatricians, is a successful model we can adapt. This custodian of community paediatrics directs traineeships, stipulates requirements and outlines the scope of the discipline.Item The ‘community’ in community case management of childhood illnesses in Malawi(Taylor & Francis Open Access, 2016) Zembe-Mkabile, Wanga Z.; Jackson, Debra; Sanders, David: Malawi has achieved a remarkable feat in reducing its under-5 mortality in time to meet its MDG 4 target despite high levels of poverty, low female literacy rates, recurrent economic crises, a severe shortage of human resources for health, and poor health infrastructure. The country’s community-based delivery platform (largely headed by Health Surveillance Assistants, or HSAs) has been well established since the 1960s, although their tasks and responsibilities have evolved from surveillance to health promotion and prevention, and more recently to include curative services. However, the role of and the form that community involvement takes in community-based service delivery in Malawi is unclear.Item Costs of implementing integrated community case management (iCCM) in six African countries: implications for sustainability(Edinburgh University Global Health Society, 2017) Daviaud, Emmanuelle; Besada, Donela; Leon, Natalie; Rohde, Sarah; Sanders, David; Oliphant, Nicholas; Doherty, TanyaBACKGROUND Sub–Saharan Africa still reports the highest rates of under– five mortality. Low cost, high impact interventions exist, however poor access remains a challenge. Integrated community case management (iCCM) was introduced to improve access to essential services for children 2–59 months through diagnosis, treatment and referral services by community health workers for malaria, pneumonia and diarrhea. This paper presents the results of an economic analysis of iCCM implementation in regions supported by UNICEF in six countries and assesses country–level scale–up implications. The paper focuses on costs to provider (health system and donors) to inform planning and budgeting, and does not cover cost–effectiveness. METHODS The analysis combines annualised set–up costs and 1 year implementation costs to calculate incremental economic and financial costs per treatment from a provider perspective. Affordability is assessed by calculating the per capita financial cost of the program as a percentage of the public health expenditure per capita. Time and financial implications of a 30% increase in utilization were modeled. Country scale–up is modeled for all children under 5 in rural areas. RESULTS Utilization of iCCM services varied from 0.05 treatment/y/under– five in Ethiopia to over 1 in Niger. There were between 10 and 603 treatments/community health worker (CHW)/y. Consultation cost represented between 93% and 22% of economic costs per treatment influenced by the level of utilization. Weighted economic cost per treatment ranged from US$ 13 (2015 USD) in Ghana to US$ 2 in Malawi. CHWs spent from 1 to 9 hours a week on iCCM. A 30% increase in utilization would add up to 2 hours a week, but reduce cost per treatment (by 20% in countries with low utilization). Country scale up would amount to under US$ 0.8 per capita total population (US$ 0.06–US$0.74), between 0.5% and 2% of public health expenditure per capita but 8% in Niger. CONCLUSIONS iCCM addresses unmet needs and impacts on under 5 mortality. An economic cost of under US$ 1/capita/y represents a sound investment. Utilization remains low however, and strategies must be developed as a priority to improve demand. Continued donor support is required to sustain iCCM services and strengthen its integration within national health systems.Item Coverage of child health services in rural districts of Ethiopia with the health services extension program(Academic Journals, 2015) Woldie, Mirkuzie; Morankar, Sudhakar Narayan; Feyissa, Garumma T.; Labonte, Ronald; Sanders, DavidImproving access to health care services has been advocated widely since the Declaration of Alma-Ata. Despite the efforts to realize this in Ethiopia, it is only in the year 2003 that the intention to take the package of essential health services to the kebele level (smallest administrative unit) was realized through the introduction of the Health Services Extension Program (HSEP). The objective of this study was to explore whether introduction of HSEP has improved the coverage of child health services in the rural areas of Jimma Zone. A cross sectional study was conducted in three randomly selected districts of Jimma Zone, Southwest Ethiopia. The data collection was undertaken during the months of May, June and July, 2009. A structured questionnaire was used to interview female heads of sampled households from nine kebeles randomly selected in three Woredas (districts). Data were collected on the socio-demographic characteristics, use of health posts, child vaccination and childhood diarrhea. Checklists were used for record review. Data obtained were analysed using statistical package for social sciences (SPSS) V14. Only 64.0% of the kebeles had functional health posts, although another 32.0% of the kebeles in the zone had health posts under construction. However, most (93.7%) of the kebeles in the zone already had two health extension workers (HEWs) assigned. Vaccination coverage as measured by DPT3 was 67.9%, and 10% of the under-two year old children included in this survey had diarrhoea during the past two weeks. Of the 34 (51.5%) mothers who sought help during diarrhoeal attacks, 12 (35.3%) of them went to the health post. The first places of treatment seeking were health centres and health posts, with equal proportion for both (43.5%). Treatment was sought within a day or two after commencement of diarrhoea for 70.6% of the children. Thirty nine (69.7%) of the 56 children who were given recommended fluids received oral rehydration solution (ORS) or homemade solution. In addition to continuing efforts to improve coverage, there is a need to ensure that activities are linked with follow up of vaccination, early treatment seeking and proper home management of diarrhoea.