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

Document Type : Original Article

Authors

1 Global Health Leadership Initiative, Yale University, New Haven, CT, USA

2 Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA

3 Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA

4 Health Extension Program, Ethiopia Federal Ministry of Health, Addis Ababa, Ethiopia

Abstract

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<0.001; 18%, p<0.001; 18%, p<0.001; respectively), as did the performance summary score (14%, p<0.001). Adherence at the zonal level in year one was associated with district level adherence in year one (p<0.001), and, over the two-year period (p<0.01), and district management mediated the relationship between management practice at zonal and health center levels (p<0.001).

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.

Keywords


  • epublished Author Accepted Version: January 22, 2022
  • epublished Final Version: February 22, 2022
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Articles in Press, Corrected Proof
Available Online from 22 January 2022
  • Receive Date: 17 April 2021
  • Revise Date: 11 January 2022
  • Accept Date: 19 January 2022
  • First Publish Date: 22 January 2022