RMNCH Service Availability and Readiness of Restructured Primary Health-care Facilities in Ethiopia: a multi-region cross-sectional assessment

Background: A responsive and resilient health system that is informed by community needs and guided by evidence-based interventions is fundamental to delivering quality essential health services and achieving Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs). Ethiopia committed to improve access to and quality of essential health services through the Health Extension Program Optimization (HEPO) roadmap, which restructured primary healthcare facilities into three categories i.e., Basic Health Posts (BHPs), Comprehensive Health Posts (CHPs), and Health Extension Program units imbedded within Health Centers (HCs). However, evidence on the reproductive, maternal, newborn, and child health (RMNCH) service availability and readiness of these restructured primary health-care facilities remains limited. Methods: This multi-region cross-sectional facility based study was conducted between December 2024 and February 2025. A structured questionnaire adapted from the World Health Organization Service Availability and Readiness Assessment (SARA) was used to measure service availability, general facility readiness, and RMNCH service-specific readiness using predefined domains and tracer items. Differences across facility types were assessed using Kruskal-Wallis or categorical association tests, with Benjamini-Hochberg adjustment for multiple comparisons. Multivariable linear regression estimated the adjusted differences in overall RMNCH readiness, controlling for region, urban-rural residence, and log-transformed catchment population, with robust standard errors clustered at woreda level. Results: A total of 305 primary health care facilities were assessed, including 107 BHPs (35.1%), 142 CHPs (46.6%), and 56 HCs (18.4%). Nearly all BHPs were located in rural settings (99.1%), compared with 86.6% of CHPs and 71.4% of HCs. The median general health facility readiness were increased significantly across facility levels, from 33.1% (IQR: 24.4-40.7) in BHPs to 62.9% (IQR: 54.1-71.4) in CHPs and 89.6% (IQR: 81.3-93.6) in HCs (p<0.001). And the median overall RMNCH service readiness was 67.9%, 77.8%, and 91.1% for BHPs, CHPs, and HCs, respectively (p<0.001). skilled Birth Attendance readiness was demonstrated the largest gap between facility types. Compared with CHPs, BHPs scored 9.9 percentage points lower in adjusted RMNCH service readiness (95% CI: -14.7 to -5.1; p<0.001), while HCs scored 8.7 points higher (95% CI: 1.7-15.8; p=0.015). Conclusions: The restructured primary healthcare facilities expanded access to essential services, particularly through CHPs, which occupy an intermediate position between BHPs and HCs through substantial expansion of RMNCH service packages for underserved communities. Nevertheless, significant gaps remain in staffing, infrastructure, commodities, diagnostics, and childbirth readiness. Future HEPO scale-up should prioritize strengthening childbirth-readiness packages and ensuring reliable supply chains for essential medicines and diagnostics.