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 2015-2019, 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 19 zones participating in PTI, which included 315 districts and 1617 health centers. METHODS: Using data from PTI intervention (2018 to 2019), 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 (1) change in management and performance during the two-year intervention, (2) 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 (37%, P<.001; 18%, P<.001; 18%, P<.001; respectively), as did the performance summary score (14%, P<.001). Adherence at the zonal level in year one was associated with district level adherence in year one (P=.04), and, over the two-year period (P=.002), and district management mediated the relationship between management practice at zonal and health center levels (P<.001). 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.

Experiences of managerial accountability in Ethiopia's primary healthcare system: a qualitative study.

BACKGROUND: Despite calls for improved accountability in global health systems, and a set of clear and consistent theoretical accountability frameworks, empirical descriptions of how accountability is experienced and enacted in low- and middle- income country (LMIC) settings is limited. Therefore, we sought to characterize how managers at all levels of Ethiopia's primary healthcare system experience accountability in their daily practice. METHODS: We conducted in-depth key informant interviews with 41 key stakeholders across 4 regions (Amhara, Oromia, Southern Nations Nationalities and Peoples, and Tigray) in the context of the Primary Healthcare Transformation Initiative (PTI). Consistent with the principles of grounded theory, our team used the constant comparative method to identify emergent themes related to concrete areas that could be targeted to allow an overall culture of accountability to flourish. RESULTS: Emergent themes were: development of a shared understanding of system-wide accountability, streamlining of managerial reporting lines, strengthening of medico-legal knowledge and systems, and development of mechanisms for bottom-up accountability. CONCLUSIONS: Findings may be valuable to policymakers seeking to create more effective national accountability frameworks; practitioners and development partners seeking to strengthen implementation of evidence-based accountability systems and practices; and researchers aiming to develop meaningful, practical measures of accountability in public health.