A Systems Approach to Improving Rural Care in Ethiopia

PLOS ONE, Dec 2019

Background Multiple interventions have been launched to improve the quality, access, and utilization of primary health care in rural, low-income settings; however, the success of these interventions varies substantially, even within single studies where the measured impact of interventions differs across sites, centers, and regions. Accordingly, we sought to examine the variation in impact of a health systems strengthening intervention and understand factors that might explain the variation in impact across primary health care units. Methodology/Principal Findings We conducted a mixed methods positive deviance study of 20 Primary Health Care Units (PHCUs) in rural Ethiopia. Using longitudinal data from the Ethiopia Millennium Rural Initiative (EMRI), we identified PHCUs with consistently higher performance (n = 2), most improved performance (n = 3), or consistently lower performance (n = 2) in the provision of antenatal care, HIV testing in antenatal care, and skilled birth attendance rates. Using data from site visits and in-depth interviews (n = 51), we applied the constant comparative method of qualitative data analysis to identify key themes that distinguished PHCUs with different performance trajectories. Key themes that distinguished PHCUs were 1) managerial problem solving capacity, 2) relationship with the woreda (district) health office, and 3) community engagement. In higher performing PHCUs and those with the greatest improvement after the EMRI intervention, health center and health post staff were more able to solve day-to-day problems, staff had better relationships with the woreda health official, and PHCU communities' leadership, particularly religious leadership, were strongly engaged with the health improvement effort. Distance from the nearest city, quality of roads and transportation, and cultural norms did not differ substantially among PHCUs. Conclusions/Significance Effective health strengthening efforts may require intensive development of managerial problem solving skills, strong relationships with government offices that oversee front-line providers, and committed community leadership to succeed.

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A Systems Approach to Improving Rural Care in Ethiopia

Citation: Bradley EH, Byam P, Alpern R, Thompson JW, Zerihun A, et al. ( A Systems Approach to Improving Rural Care in Ethiopia Elizabeth H. Bradley 0 Patrick Byam 0 Rachelle Alpern 0 Jennifer W. Thompson 0 Abraham Zerihun 0 Yigeremu Abeb 0 Leslie A. Curry 0 Thomas Eisele, Tulane University School of Public Health and Tropical Medicine, United States of America 0 1 Yale School of Public Health, Global Health Leadership Institute (GHLI), Yale University , New Haven , Connecticut, United States of America, 2 Ethiopian Millennium Rural Initiative (EMRI), Clinton Health Access Initiative (CHAI) , Addis Ababa , Ethiopia Background: Multiple interventions have been launched to improve the quality, access, and utilization of primary health care in rural, low-income settings; however, the success of these interventions varies substantially, even within single studies where the measured impact of interventions differs across sites, centers, and regions. Accordingly, we sought to examine the variation in impact of a health systems strengthening intervention and understand factors that might explain the variation in impact across primary health care units. Methodology/Principal Findings: We conducted a mixed methods positive deviance study of 20 Primary Health Care Units (PHCUs) in rural Ethiopia. Using longitudinal data from the Ethiopia Millennium Rural Initiative (EMRI), we identified PHCUs with consistently higher performance (n = 2), most improved performance (n = 3), or consistently lower performance (n = 2) in the provision of antenatal care, HIV testing in antenatal care, and skilled birth attendance rates. Using data from site visits and in-depth interviews (n = 51), we applied the constant comparative method of qualitative data analysis to identify key themes that distinguished PHCUs with different performance trajectories. Key themes that distinguished PHCUs were 1) managerial problem solving capacity, 2) relationship with the woreda (district) health office, and 3) community engagement. In higher performing PHCUs and those with the greatest improvement after the EMRI intervention, health center and health post staff were more able to solve day-to-day problems, staff had better relationships with the woreda health official, and PHCU communities' leadership, particularly religious leadership, were strongly engaged with the health improvement effort. Distance from the nearest city, quality of roads and transportation, and cultural norms did not differ substantially among PHCUs. Conclusions/Significance: Effective health strengthening efforts may require intensive development of managerial problem solving skills, strong relationships with government offices that oversee front-line providers, and committed community leadership to succeed. - Funding: This research was funded through a grant from the Childrens Investment Foundation Fund. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Improving access to and quality of rural primary health care, especially in low-income settings, is a global priority [12]. Multiple efforts have been directed at improving access and use of primary care services, particularly among women and children in rural settings [35]; however, the success of these interventions varies substantially, even within single studies where the measured impact of interventions can differ across different sites, centers, and regions [6]. Several previous health systems strengthening efforts directed at improving rural primary care in low-income countries have been relatively successful [79]. At the same time, other efforts have met with weaker outcomes [1012]. Prior research has identified the cost, level and quality of available health services [7,1314], distance and transportation [1416], and social and cultural norms [1718] as site-level factors influencing the utilization of primary health care services. Although this literature is useful, studies typically report overall effects, limiting our understanding of the heterogeneity in effects across different intervention sites even within the same study. As a result, we know relatively little about why the same set of interventions may be effective in one rural health care unit and less so in another. Accordingly, we sought to generate hypotheses about factors that may explain the variation in performance across primary health care units. Using longitudinal data from the Ethiopian Millennium Rural Initiative (EMRI), a health systems strengthening effort designed to improve the performance of rural primary health care units (PHCUs) located throughout 4 regions in Ethiopia, we categorized PHCUs into three types: PHCUs with consistently higher performance, PHCUs with the most improved performance, and PHCUs with consistently lower performance. Because our goal was to generate hypotheses (...truncated)


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Elizabeth H. Bradley, Patrick Byam, Rachelle Alpern, Jennifer W. Thompson, Abraham Zerihun, Yigeremu Abeb, Leslie A. Curry. A Systems Approach to Improving Rural Care in Ethiopia, PLOS ONE, 2012, Volume 7, Issue 4, DOI: 10.1371/journal.pone.0035042