An Analysis of Zonal Health Management Capacity and Health System Performance: Ethiopia Primary Healthcare Transformation Initiative

Background  District management is emerging as a lynchpin for primary healthcare system performance. However, delivery of district-level interventions at scale is challenging, and overlooks the potential role of management at other subnational levels. From ۲۰۱۵-۲۰۱۹, Ethiopia’s Primary Healthcare Transformation Initiative (PTI), aimed to build a culture of performance management and accountability at the zonal level. This paper aims to evaluate the longitudinal change in management practice and performance in the ۱۹ zones participating in PTI, which included ۳۱۵ districts and ۱۶۱۷ health centers.Methods  Using data from PTI intervention (۲۰۱۸ to ۲۰۱۹), we employed quantitative measures of management capacity at health center, district, and zonal levels, and quantified primary healthcare service performance using a summary score based on antenatal care coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. We used multiple generalized linear regression models accounting for clustering of health centers within zones to quantify (۱) change in management and performance during the two-year intervention, (۲) associations between the changes in management capacity at the zonal, district, and health facility level.Results  Adherence to management standards at the zonal, district, and health facility level improved significantly over two years (۳۷%, p<۰.۰۰۱; ۱۸%, p<۰.۰۰۱; ۱۸%, p<۰.۰۰۱; respectively), as did the performance summary score (۱۴%, p<۰.۰۰۱). Adherence at the zonal level in year one was associated with district level adherence in year one (p<۰.۰۰۱), and, over the two-year period (p<۰.۰۱), and district management mediated the relationship between management practice at zonal and health center levels (p<۰.۰۰۱).Conclusion  Improvements in zonal-level management practice were associated with significant improvements in district-level management and performance in PTI sites. Investments in managerial practices at the zonal level may provide an immediate way to energize primary healthcare system performance at scale in low-income country settings.

Keywords:

Primary Healthcare , Sub-national Interventions , Health Management Capacity , System performance , Ethiopia , Sub-Saharan Africa