Access and quality of rural healthcare: Ethiopian Millennium Rural Initiative
JENNIFER W. THOMPSON
TASHONNA R. WEBSTER
Department of Medicine, Division of Cardiology, Yale University
New Haven, CT
USA and Health Research and Educational Trust
Chicago, IL, USA
Clinton Health Access Initiative
, Addis Ababa,
Yale School of Public Health
New Haven, CT, USA
Objective. More than half the world's population lives in rural areas; however, we have limited evidence about how to strengthen rural healthcare services. We sought to determine the impact of a systems-based approach to improving rural care, the Ethiopian Millennium Rural Initiative, on key healthcare services indicators. Design. We conducted an 18-month longitudinal mixed methods study of the 10 primary healthcare units (PHCUs) serving 400 000 people, using monthly indicator tracking and focus groups.
Nearly half the population in the globe lives in rural
communities  where healthcare services are typically less available
and of poorer quality than in semi-urban and urban settings
. The rural urban disparity is apparent in high-income 
and middle-income [4, 5] countries; however, this
discrepancy is most pressing in low-income countries, particularly
in sub-Saharan Africa, where more than 60% of the
population lives in rural areas , with long travel distances
to healthcare facilities [7 9]. Consequently, any effort to
strengthen health systems must incorporate a strategy to
improve both the access to and the quality of healthcare
services in rural areas.
Previous research in sub-Saharan Africa has identified
several interventions shown to be effective in specific areas of
rural healthcare, including enhanced access to antiretroviral
treatment [10 12], antenatal care , infant care [14, 15],
tuberculosis detection and treatment , and malaria
prevention and treatment [17 19]. However, previous studies have
not examined the effectiveness of systems-based approaches
in which primary care is extended to rural areas and
supported by supply chain, human resource management,
monitoring and finance reform efforts.
Accordingly, we sought to determine the impact of a
systems-based approach to improving rural care, the
Ethiopian Millennium Rural Initiative (EMRI), on key
healthcare services indicators; we hypothesized that there would be
significant improvement in these key indicators. The EMRI,
which was designed to strengthen primary healthcare units
(PHCUs) in Ethiopia in an 18-month period, provided an
ideal opportunity to examine the impact of a health systems
strengthening intervention in one of the lowest-income
countries in the world and among extremely rural
populations. Understanding the impact of EMRI can provide
insights for other countries in which elevating rural
healthcare services is a priority.
Ethiopia is a country of 80 million people, and is ranked
177 out of 182 on the Human Development Index of the
United Nations . In 2007, the country spent 3.8% of
its gross domestic product on health . With ,1 physician
and 2 nurses per 10 000 population , the country is far
below WHO recommendations for the number of health
professionals necessary to achieve key health indicators .
Despite task-shifting initiatives , HIV testing remains
limited, and key maternal and child health indicators, such as
use of antenatal care and skilled birth attendant rates, remain
low across the country . Rural healthcare has been noted
as a particular problem in Ethiopia, which had fewer than
700 health centers in 2007 . Although the country has
undertaken an enormous expansion of health extension
workers and health centers, currently, fewer than half of the
rural residents of Ethiopia live within walking distance of a
healthcare facility .
The EMRI, a centerpiece of the countrys overall health
sector development efforts, is a systems-based initiative to
develop a successful model of rural primary healthcare that
is scalable across the country. By systems-based, we mean
healthcare improvement efforts that target all patients rather
than those with specific diseases and that can be
standardized and replicated across the country over time.
Implemented by the Ethiopian Federal Ministry of Health
(FMOH) with support from the Clinton Health Access
Initiative (CHAI), EMRI employs a systems-based approach
to strengthen health centers with the goal of increasing
access to, and quality of services available in, rural settings.
The elements of the EMRI model include: (i) improving
the infrastructure of health centers (i.e. water, electricity,
physical infrastructure and equipment), (ii) improvement in
the supply chain (e.g. transport of specimens and results
follow-up), (iii) human resource capacity building through
health worker training and on-site clinical mentoring, (iv)
developing a system to improve referrals between health
posts and health centers and (v) community education and
mobilization. Additionally, the EMRI features new services,
including HIV testing at the health posts and establishment
of prevention of mother-to-child transmission (PMTCT) of
HIV programs at health centers. The EMRI is consistent
with the overall strategy of Ethiopia in the Health Extension
Program (HEP), particularly in its focus on staff training for
health posts and community mobilization; however, EMRI
additionally includes focused efforts to improve health center
infrastructure, supply chain and referral systems, to provide
on-site clinical mentoring at health centers, and to extend
HIV testing to the health posts.
Study design and sample
We conducted a longitudinal mixed methods study of the 10
PHCUs where EMRI had been in place for 18 months, each
of which served a catchment area of 40 000 people. The
10 PHCUs were selected in two regions (Oromia and
Amhara regions) by the FMOH as priorities for
improvement. Each PHCU included 1 health center, 5 health posts
(each with 2 health extension workers) and an average of 200
volunteer community health workers. We collected
quantitative data on health services utilization of the 10 PHCUs
monthly for 18 months. We also conducted focus groups, as
they are appropriate for topics that involve social norms, and
are useful in revealing the diversity and consensus of
opinions regarding a given issue . We conducted two
waves of focus groups: the first within 3 months of the
initiation of EMRI, and the second completed 1 year later in
the same catchment areas, until we reached theoretical
saturation, i.e. until no new concepts occurred with successive
focus groups . This occurred after 14 focus groups
(1 male and 1 female in each of 7 PHCU areas) in the first
wave and 14 groups in the second wave, with a total of 28
focus groups. Participants were diverse with regard to
residence within their catchment area, occupations and age
(minimum of 16 years). Nearly all participants had some
experience with the health center; only three participants
reported that they had not visited the health center but had
received visits from health extension workers at their homes.
We stratified groups by gender to encourage open
discussions about potentially sensitive health-related issues. Because
this paper focused on perceptions of changes in access and
quality of services since the inception of EMRI, the present
analysis includes data from the 12-month follow-up focus
groups, which were composed of 10 people each, or a total
of 140 participants.
Quantitative data on a set of five indicators (Table 1) were
collected monthly by PHCU staff and corroborated through
on-site checking of data reports by the research team every 6
months. Indicators, most of which were also required as part
of the countrys Health Management Information System
(HMIS), measured utilization of antenatal care, use of skilled
birth attendants, HIV testing in antenatal care, HIV testing
in the population aged 15 40 years at both the health center
level and the health post level, and general outpatient visits.
Data were recorded monthly on paper forms by PHCU staff,
entered into Microsoft Excel by EMRI Regional Managers,
Table 1 Time trends for key indicators
Indicator ba P-value
Antenatal care coverageNumber of
pregnant women attending their first
antenatal care visit by number of predicted
pregnancies in catchment area per month2
Skilled birth attendant coverageNumber
of deliveries by skilled birth attendants by
number of predicted pregnancies in
catchment area per month
Antenatal care HIV testing coverage
Number of pregnant women receiving
HIV testing and counseling during their
first ANC visit by number of first ANC
visits per month
Health post and health center HIV testing
coverageNumber of persons receiving
HIV testing and counseling at a HP or HC
by catchment area population ages 15 49
Outpatient visit rateNumber of
outpatient visits by catchment area
population per month
ab-values were calculated using dependent variables expressed as
annualized percentage points.
bEstimates of the number of pregnant women in each health center
catchment area were calculated using the regional birthrate.
cEstimates of the number of persons aged 15 49 in each health
center catchment area were calculated using regional population
data from the 2007 Ethiopian census.
dHIV testing at the health post level began 10 months into the
intervention, in July 2009.
and reviewed for accuracy and completeness quarterly by our
The focus group discussion guide (Appendix) used
openended questions  to foster discussion of community
perspectives on the availability and quality of services at the
health center and health post, the degree to which these
services met community needs, and changes in health delivery in
the PHCU over time. Each focus group lasted 1 h. Focus
groups were coordinated by researchers from Addis Ababa
University who spoke Amharic and Oromiffa and were
experienced in facilitating focus groups. All sessions were
audio-taped after researchers obtained participant consent.
Audiotapes were transcribed in Amharic or Oromiffa as
appropriate and then translated into English, producing 374
pages of transcripts for the present analysis. All research
procedures were approved by the Institutional Review Board at
the Yale School of Medicine and the Ethiopian FMOH.
To estimate the trend over time in each performance
indicator, we used linear regression analysis using monthly
outcome data from the 10 PHCUs. From the regression line,
we estimated the rate of change in each indicator over time
and tested its statistical significance using Wald statistics. We
used PROC MIXED in SAS to account for repeated
measures for each health center. Although plots of the data
suggested a largely linear relationship between each indicator
and time, we assessed parabolic and higher-order functions
to ensure the best fitting specification of the time trends.
Higher-order terms were non-significant; hence we report
estimates from the linear models. All data analyses were
performed using Excel and Statistical Analysis System (SAS),
For analysis of the qualitative data, we employed the constant
comparison method [30 32] to determine key themes from
the focus groups. Two members of the research team (R.A.,
T.R.W.) conducted a line-by-line review of transcripts and
developed codes inductively [31, 33]. Throughout the coding
process, we constantly compared the content with previously
coded data to ensure consistent assignment of codes. This
iterative process of refining codes and describing properties of each
 continued until no new concepts emerged and the final
coding structure was established. Using a refined final version
of the code structure, the team independently coded all focus
group transcripts . In order to ensure scientific rigor, we
consistently used the focus group discussion guide,
standardized coding and data analysis of focus group transcripts, and
created an audit trail to document analytic decisions [32, 36,
37]. We report themes that are pertinent to the quantitative time
trend data. We used ATLAS.ti (Version 5.0.67; Scientific
Software Development GmbH, Berlin, Germany) to facilitate
data coding, organization and retrieval.
The sample of PHCUs (n 10) included 4 facilities in
Amhara and 6 facilities in Oromia region of Ethiopia,
and served more than 402 000 people with an average of
13 employees. Participants in the 14 focus groups used for
this analysis (n 140) ranged in age from 16 to 78, with an
average age of 37 years (Table 2). The majority of
participants were married in both the male (84%) and female
(73%) focus groups.
Time trends in key indicators
Significant improvement (P-values of ,0.05) over time was
apparent in four of the five indicators (Table 1) including
antenatal care visits and use of skilled birth attendants
(Fig. 1), HIV testing in antenatal care (Fig. 2) and overall
HIV testing (including testing performed at the health center
and testing performed at the health posts) (Fig. 3). The
estimated proportion of pregnant women in the catchment area
that received antenatal visits increased from about 40 100%.
In addition, by the end of the study period, about 85% of
women who received antenatal care also were tested for HIV.
Table 2 Characteristics of focus group participants
Male Female Total
Figure 1 Antenatal care coverage and skilled birth attendant
rate over time. *Percentage of pregnancies derived from
catchment area population and annual regional birthrates.
Average antenatal care visit coverage: b 41.4, P-value of
,0.002, R2 0.53. Average skilled birth attendant coverage:
b 2.6, P-value 0.015, R2 0.60.
Overall, HIV testing increased nearly 4-fold, to cover 5% of
the 15 49-year-old population in the catchment areas, and
use of skilled birth attendants nearly doubled, although it
remained limited at only 10% of expected deliveries in the
catchment area. In data not shown, the significant increase in
HIV testing rates occurred at different levels of facilities in
the different regions. In Oromia, the significant increase was
at the health post level, while in Amhara the significant
increase took place at the health center level. For the
remaining indicator (outpatient visits), improvement was apparent at
Figure 2 HIV testing in antenatal care rate over time.
*Average HIV testing in ANC coverage: b 26.1, P-value
of ,0.001, R2 0.54.
Figure 3 Monthly rate of HIV testing (at health center or
health posts) over time. *Average total HIV testing coverage
at HC or HP: b 2.7, P-value of ,0.001, R2 0.39.
individual PHCUs but was not statistically significant overall
Community member experiences
Focus group discussions revealed diverse views regarding the
accessibility and quality of services, ranging from highly
positive observations of substantial improvements in some
services, to continued unmet needs and expectations for other
services, such as those available at more urban facilities.
Recognition of improved services
Participants noted improvements in availability of antenatal
care at the health centers, longer hours of operation and
availability of skilled birth attendants at the health centers,
and increased receipt of HIV testing as part of antenatal care
and for the general adult population. They noted increased
accessibility facilitated by health extension workers and health
Figure 4 Monthly rate of outpatient visits at health centers
over time. *Average outpatient visits at health centers:
b 0.4, P-value 0.279, R2 0.65.
Antenatal care and use of skilled birth attendants. Focus group
participants noted substantial improvement in antenatal care,
as was also evident from the quantitative data. Improvements
included better understanding of the antenatal period in
pregnancy, access to regular check-ups and qualified health
workers to perform antenatal care visits. One man from
Amhara described changes in womens understanding of
how to prepare for childbirth:
Previously, pregnant women did not know when they were to
deliver. But now they are getting a very good check up. There is
started five or six months before. Pregnant women used to
refuse to go to the health workers. Now the health workers teach
the people and pregnant women rush to get the [antenatal]
(Male, Amhara region, HC #1)
A woman from Oromia described how health promoters had
changed womens views about the importance of both
antenatal and post-natal care available at the health centers.
Previously, pregnant mothers did not often come to this health
center. But, after the health promoters got this training, they
began to mobilize women in our area to seek health services
provided by the health center by explaining to them that it is
beneficial for both mothers and children. As a result, mothers
are now increasingly getting antenatal and post-natal health care
services from the health center. There is very good service in the
(Female, Oromia region, HC #2)
Participants also noted increased availability of staff and
medicines at the health centers to facilitate child birth in the
health centers, suggesting that these changes reduced the
need to travel long distances to a hospital to give birth. For
instance, one woman in Oromia said:
To give birth before, I was referred to Black Lion Hospital. But
now, since the health care professionals started working 24 hr
anyone who seeks service can get the required services easily.
The situation is much improved. Due to the expansion of the
service time availability, recently two women gave birth at this
health center peacefully. Through observing each other, the
community members will also start to come to the center more
(Female, Oromia region, HC #2).
HIV testing of pregnant women and overall. Both women and
men commented on the increased availability and acceptance
of HIV testing. Several participants referenced what one
male participant said was awareness creation and community
mobilization through home visits [by community health
promoters] to initiate people to take HIV tests (Male,
Oromia region, HC #9). Recurrent observations about HIV
testing of pregnant women were consistent with the
quantitatively significant increases in HIV testing in antenatal
care visits. One female from Amhara said,
A pregnant woman undertakes voluntary counseling and testing
(VCT) for HIV/AIDS along with her husband. The couples are
obliged to treat health conditions that might be transmitted to
their child. I undertook VCT and they told me my husband had
to follow suit.
(Female, Amhara region, HC #1).
Participants described acceptance of HIV testing as routine,
especially among younger people, regardless of pregnancy
status. Illustrating this perspective, one woman in Amhara
The young have a good knowledge about HIV/AIDS and they
come to get tested without anybody telling them to do so. Many
young people are coming to the health center and testing. This is
a big change.
(Female, Amhara region, HC #3)
Health posts and health extension workers. Many participants
expressed major challenges due to the long distance and
difficult terrain between their homes and the health centers.
The strengthening of health posts, staffed with health
extension workers, and contracting with community health
workers through the EMRI was noted by several
participants, particularly in terms of the availability of HIV
testing at health posts. In Oromia, one participant said, the
health education provided by the health post and health
extension workers should not be underestimated (Male,
Oromia, HC #9), and participants described effective
educational efforts undertaken in public squares, in churches
and in social gatherings. One man from Amhara stated:
HIV/ AIDS diagnosis was only available in the health center
before, but now it is brought down to the neighborhood level on
the health posts. And health workers were trained for this
purpose. At [this] health post, many people got tested.
(Male, Amhara region, HC #1)
Participants observed that health extension workers were
effective in tracking pregnant women who were HIV positive
so as to ensure that they were supported with proper
treatment to reduce likelihood of vertical transmission of HIV.
One man in Amhara commented,
The health [extension] workers follow [women] when they are
pregnant, and there are HIV positive mothers who gave birth. I
dont know how they follow the mothers. I dont know the
secret, but they take care of them.
(Male, Amhara region, HC #1)
Overall, participants described a gradual process of the
community, increasing their acceptance of health extension
workers, as reflected in this comment from an Amhara
There is a farmer who comes to my tea house to have tea
whenever she comes to [town]. She explained to me that at first she
was totally against the health post workers and was not even
willing to let them in her house. But eventually, she started to
appreciate and be grateful for what the health extension workers
have done to change her family and her life style. The health
extension workers in the health station were at first were disliked
by the community, now, however they are highly appreciated and
liked after what they do is seen.
(Female, Amhara region, HC #1)
Unmet needs and expectations
Despite participants views of improved availability of many
services, they still reported substantial unmet needs and
expectations. These unmet needs related to perceptions of
inadequate diagnostic equipment at the health centers, quality
of skilled birth attendants at the health centers, and level of
staff and equipment at the health posts.
Access to services. Rural community members described that
services remained difficult to access due to the distance to
the health center or hospital and limited quality and
comprehensiveness of services at some health centers,
particularly compared with more urban or semi-urban health
centers, as this man from Amhara observed:
. . . the health center doesnt have complete equipment to make
the diagnosis. It is still backward. Compared with the HCs in the
other woredas [districts], the [name] HC still lacks indispensable
equipments to offer satisfying service.
(Male, Amhara region, HC #3)
Quality of childbirth services. Several participants voiced
unmet expectations about childbirth services at the health
centers. These participants suggested that, although new
skilled birth attendants were available at health centers, there
was skepticism regarding the quality of care they provided. A
man from Oromia stated:
The expectant mothers from distant [towns] do not come to the
health center for delivery service . . . they do not feel confident in
the professionals skill and capacity of giving delivery service.
Usually, as there are no adequate materials in the health center, it
is mostly seen that women are given referrals to other health
institutions, and this situation jeopardizes the life of the women
. . .
(Male, Oromia region, HC #9).
Furthermore, some participants reflected that even with
greater numbers of better trained staff and more equipment,
the health centers were limited in their capacity to address
more complex birthing needs, reducing the likelihood that
women would use the health centers for childbirth.
A woman in Amhara stated:
The health center provides delivery services day and night. It has
the equipment and the qualified staff to do so. But there is a lack
of beds for pregnant women who need to stay overnight and get
medical help. Plus the center does not undertake medical
operations due to lack of high expertise.
(Female, Amhara region, HC #1)
Additionally, participants expressed concerns about the
quality of general outpatient care at the health center, as a
man in Amhara explained,
Nobody comes to the health center to make check-ups. Even
when people get flus or colds, they would rather treat them with
traditional medicines as they think that they wont get solution at
the health center.
(Male, Amhara region, HC #3)
Staffing and equipment at health posts. Participants
indicated that their communities would benefit if their health
posts had the same level of staff and equipment as the
health centers, and if their health centers were able to
offer surgery and other advanced treatments available in
urban hospitals. The desire for such changes was driven
primarily by long distances and limited transportation. A
man in a particularly remote community in Oromia
suggested that the health posts be enhanced to the level
of health centers, saying,
The fundamental problem we are facing . . . is lack of equivalent
service we need at the kebele [neighborhood] level. With the
difficulty of transportation accessibility, we need to get the medicines
and diagnosis for simple diseases at our vicinity.
(Male, Oromia region, HC #9)
We found significant improvements in several targeted
indicators in the EMRI program, after 18 months of
operation. These included antenatal care coverage, use of
skilled birth attendants, HIV testing in antenatal care and
HIV testing overall. Focus group data indicated that
increased use of these services was fostered in part by
the expansion of health extension workers and voluntary
community health workers, who were successful in
educating and encouraging people in rural settings to use health
center and health post services. The strategy of using
community health workers for health education and
linkages to services has been successful in other low-income
settings [38, 39] and remains a core element of Ethiopias
health system strengthening efforts. According to our
findings, this strategy is likely to be successful in
improving service use in some areas.
Despite these positive improvements, peoples experiences
of the health centers and health posts as described in focus
groups were mixed, underscoring the importance of
integrating quantitative and qualitative measures of impact.
Perceptions of longer hours of operation, more qualified
staff, and increased supplies and medications were apparent;
however, many participants expressed disappointment in the
level of services offered, comparing the strengthened health
center to hospitals and health centers in more urban settings.
Participants repeatedly noted the need for more qualified
staff and greater equipment, particularly for performing
surgical procedures for complicated childbirth. With the
increased focus on the millennium development goal
concerning maternal mortality [40, 41], rural initiatives such as
EMRI may be important to begin the process of antenatal
care; however, greater investment in complicated childbirth
services will be critical.
Our findings should be interpreted in light of several
limitations. First, we were unable to have a comparison
group against which to examine progress over time; this is
because other rural health centers did not routinely report
data on HMIS indicators, as that system had not been
widely implemented at the time of our study. Ethiopia has
increased awareness of the need for HIV testing through
many health education efforts throughout the country in
recent years, and some of the improvement in HIV testing
in the EMRI PHCUs could be due to these broader
efforts; however, since non-EMRI rural health centers are
still developing the staffing and systems needed to provide
routine care, it is unlikely that they fully explain the
observed improvements. Second, given the limited
information technology in rural Ethiopia, data were gathered on
paper and then entered into a computer centrally in Addis
Ababa, which may have resulted in some errors.
Nevertheless, we minimized the likelihood of such errors
through the use of a consistent data capture form with
detailed definitions of each input, and corroboration of
data every 6 months by our research team using original
registers to cross-check data. Finally, we conducted the
study in a single country with an intervention that was
broadly supported by the Ministry of Health; results may
differ in other settings or where such political and
instrumental support was not available.
The study describes overall improvement in several key
areas using a systems-based approach to strengthening
primary healthcare units; however, regional differences were
apparent in how PHCUs accomplished their improvements.
For instance, the expansion of HIV testing to the health post
level was particularly important in one region. Additionally,
we found variation in improvements even across health
centers, with some demonstrating more substantial
improvements in various indicators than others. Such variation
underscores the complexity of predicting change and
potential expansion of individual models of care, such as EMRI.
Future research to identify the various elements of successful
change, including, but not limited to, facility and
governmental leadership, community engagement and economic
resources, would be helpful in anticipating the potential
effects of such interventions as they may be scaled up in
This research was funded through a grant from
Childrens Investment Foundation Fund.
Appendix: Focus group discussion guide
1. Please tell us about the healthcare services you can get at
the health center
Prevention of Mother to Child Transmission of HIV/
Malaria diagnosis and treatment?
Tuberculosis diagnosis and treatment?
2. Do the services currently offered by the health center
meet the needs of the community?
If yes, how so?
How can the services that are available be made better?
What services not currently available would be the most
valuable to have?
What keeps you from getting the services you need?
What do you think would help take care of those problems?
3. Please tell us about how often you use the services
provided by the health center
How much do the services cost, and how do they get paid for?
We want to hear about the healthcare professionals at the
health center. Can you tell us about how they work?
How can the healthcare professionals better serve you?
4. In general, please tell me what you have liked about your
healthcare services and what you have not liked (please consider
all kinds of services including health center and hospital care)
Are there any other ways that the health center can make
the healthcare in your community better?
5. Please tell us about the healthcare services you can get at
the health post?
Do the services currently offered by the health post meet
the needs of the community?
Please tell us about how often you use the services
provided by the health post
In general, are there any ways that the health post can
make the healthcare in your community better?
6. We would like to hear more about health extension workers.
Can you tell us about the work that they do in your community?
7. We would like to hear more about community health promoters. Can you tell us about the work that they do in your community?
8. Have there been any changes in the last 6 months
that have made a difference for you and the community?
9. We are trying to understand how you feel about the healthcare services in your community. Is there anything else we should have asked that would help us understand this better?
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