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.

15. Zone health department starts and maintains Community Based Health Insurance (CBHI) scheme in all woredas. 16. Zonal Health Department coordinates community contribution and ownership on community based public health interventions.
Chapter 4. Coordination with other sectors 17. Coordinate execution of national and RHB initiatives by Woreda health offices and health facilities 18. Inter-sectoral coordination mechanisms established 19. Coordinate and align activities of development partners, and civil society organizations. 20. Private health facilities work in alignment with priorities of the woreda and operate within the national regulatory framework.
Chapter 5. Performance management 21. Zonal Health Department develops and reviews woreda based plan and targets. 22. System for performance review established and operational in General Hospitals, Woreda Health Offices and Primary Health Care Facilities. 23. Performance of General Hospitals, Woreda Health Office and Primary Health Care Facilities is monitored using evidence from; KPIs, EHRIG, EHCRIG and WMS. 24. Zonal Health Department establishes and implement bottom-up performance accountability mechanisms at zonal, woreda health and primary health facilities 25. Zonal Health Department compiles and disseminates national and regional policies, guidelines and manuals used as references for performance management. 26. Conduct supportive supervisions to General Hospitals, Woreda Health Offices and Primary Health Care Facilities Appendix Table S2. Zonal Management Standards (detailed) Chapter 1. Governance and organizational capacity ZMS 1. The organizational structure of the Zonal Health Department reflects its core functions and comprising core processes and case teams responsible to execute the following core functions. ZMS 1.1 Planning, monitoring and evaluation of health care services within the zone. ZMS 1.2 Planning and coordinating supportive supervision, mentoring and technical support to General Hospitals, Woreda Health Offices and Primary Health Care Facilities ZMS 1.3 Coordinate resource mobilization for General Hospitals, Woreda Health Offices and primary health care facilities. ZMS 1.4 Ensuring community engagement and ownership ZMS 1.5 Disease surveillance and coordinating and planning emergency response for public health emergencies. ZMS 1.6 Conducting regulatory functions. ZMS 1.7 Coordination with other sectors at the Zone level and linkage between RHB, General Hospitals and Woredas. ZMS 1.8 Ensuring efficient utilization of financial resources by zonal health department ZMS 1.9 Ensuring the proper human resources managements at zonal health departments ZMS 1.10 Overseeing medical supplies and equipment to General Hospitals and Primary Health Care Facilities. ZMS 1.11 Superintending the fulfilment of infrastructures to General Hospitals, Woreda Health Office and primary health care facilities ZMS 2. Zonal Health Department ensures governing boards of General Hospitals and Primary Health Care Facilities (HCs, PHs) are functional. ZMS 2.1 All governing boards of General Hospitals and primary health care facilities are functional. Zonal Health Department, presenting cases to the Zone administration/city mayor, ensures that corrective action is taken on governing boards that do not meet regularly. ZMS 2.2 Minutes of governing board meetings include; review of action points from previous meeting, performance review using KPIs and way forward action points. ZMS 6. Zonal Health Department provides oversight and facilitates procurement of goods and services by General Hospitals and Primary Health Care Facilities. ZMS 6.1 Zonal Health Department compiles procurement needs (goods and services) including essential drugs by General Hospitals and primary health care facilities under woredas. ZMS 6.2 Zonal Health Department monitors that procurement are executed timely by General Hospitals, primary hospitals and health center and maintains checklist showing list of items requested vs. procured. ZMS 6.3 Zonal Health Department has ensured implementation of LMIS (Logistics Management Information System) in General Hospitals and Primary Health Care Facilities. ZMS 6.4 The Zonal Health Department oversees zero stock out rates across all essential drugs at Primary Health Care Facilities. ZMS 6.4 The ZHD maintain records of all drugs and medical supplies it holds in stock, the amounts of each item requested by the health facilities and the amounts actually distributed, by date. A report of this data is submitted quarterly to the Zone's Management Committee for review. ZMS 6.5 The ZHD coordinates quality assurance on primary health care facilities laboratory services. ZMS 6.6 The ZHD maintains blood bank services to general hospital and primary health care facilities. ZMS 6.7 The ZHD maintain an inventory of all items of equipment that require maintenance, vehicles and motorbikes by health facility and Woreda Health Office. This inventory is updated quarterly and included details of maintenance needs. The full inventory is submitted twice per year to the RHB. ZMS 6.8 Coordinate quarterly equipment maintenance for zonal and primary health care facilities based on the identified needs.
ZMS 7. Zonal Health Department ensures that General Hospitals, Woreda Health Offices and Primary Health Care Facilities have basic infrastructure requirements: buildings, communications, electricity and water. ZMS 7.1 Zonal Health Department keeps and update bi-annually a record of status of buildings, communications, electricity, and water availability for General Hospitals, Woreda Health Offices and primary health care facilities. ZMS 7.2 Zonal Health Department bi-annually develops a plan of action in consultation with Woreda health offices, facility governing boards, Zone and woreda Administration and other relevant stakeholders to fill identified infrastructure gaps in building, communications, electricity, and water.
Chapter 2. Health service delivery ZMS 8. Zonal Health Department supports availability of secondary hospital services at General Hospitals and essential package of basic health care services at Primary Health Care Facilities (Review secondary health care services and essential package of basic health care services). ZMS 8.1 Zonal Health Department maintains an updated record of secondary health care services provided at General Hospitals and essential package of basic health care services available in each Primary Health Care Facilities. ZMS 8.2 Zonal Health Department ensures secondary health care services are provided at General Hospitals and essential package of basic health care services are available in each Primary Health Care Facilities. ZMS 9. There is a referral and linkage system between General Hospitals and Primary Health Care Facilities in the Zone. ZMS 9.1 Zonal health department ensures all general and Primary Health Care Facilities use standard referral and feedback protocol including standard referral and feedback forms and registers. ZMS 9.2 Zonal Health Department organizes quarterly referral feedback meeting between general hospitals and Primary Health Care Facilities where data on referral, feedback, and unnecessary referrals are reviewed. ZMS 9.3 Ambulance administration policy is in place and operational in General hospitals and all primary health care facilities. ZMS 11. Zonal Health Department coordinates clinical mentoring between primary hospitals and health centers. ZMS 11.1 Zonal Health Department working with the CEO of General hospitals, Woreda Health Offices and Primary Hospitals develops schedule of clinical mentoring sessions between Zonal, primary hospital and all health centers. (Clinical mentoring may include one-on-one case management and observation, chart reviews, attachments, and didactic sessions). ZMS 11.2 Zonal Health Department organizes knowledge and skills assessments of mentees semi-annually in collaboration with General Hospitals, Woreda Health Offices, and primary hospital to monitor the outcome of mentoring. ZMS 11.3 Zonal Health Department organizes trainings or mentoring sessions in collaboration with the Zonal and primary hospital based on knowledge and skills gap identified.
ZMS 12. Monitor outbreak and public health emergencies (Surveillance report and Emergency response plan) ZMS 12.   The Health Center Governing Board conducts regular meeting at least once in three months 3.
The Body approves annual and strategic plans for the health center to achieve its goal of improving its community's health and welfare and evaluate its achievement versus plan every quarter. 4.
The health center director is assigned by the city administration or woreda health office. The health center director organize and lead the heath center management committee comprised of different case teams.

5.
The health center director is evaluated quarterly, consistent with operational and strategic plans as established by the Body and the manager collectively. 6.
Health center director plan versus achievement report is monthly submitted to the wored health office 7.
Free and fee for health services that clients pay at reception and cashier are posted at health notice board in clear and visible manner 8.
The health center has signed memorandum of understanding agreement with entities that it provides free or credit health care services 9.
The health center finance officer presents the detailed status of health center financial reports to the health center management committee 10.
The health center has procurement plan approved by the health center governing body 11.
Health center financial manual is approved by the health center governing board and bears the seal of the of health center on it 12.
The health center finance is at least annually audited by the woreda finance office Domain 2. HEALTH POST SUPPORT 13.
The health center has established the necessary structural arrangement to implement linkage with health posts including assigning personal to manage and follow the system. 14.
A one to five linkage is established in the catchment community and the functionality is assured 15.
The health center creates linkage with 5 health posts under its custody and ensures its functionality 16.
The health center prepares core plans as a PHCU for the health posts under its custody and engage the community and relevant stallholders 17.
A detailed time table and plan is developed for each professional in the health center to support health extension workers at each Development Group. 18.
The health center collect and analyze weekly performance reports from health posts and organize a regular review meetings to follow the overall progress in major community activities, to identify best practices and to share it among health posts. 19.
The health center sends a timely and appropriate feedback to the health posts and follows the implementation of the feedback during regular support. 20.
The health center organizes an integrated and a regular supportive supervision to identify major gaps and to support accordingly. 21.
The health center allocates appropriate supplies to health posts and follows their appropriate use. Domain 3. PATIENT FLOW 22.
Procedures are established to ensure efficient patient flow; such procedures are specific to emergency, outpatient and delivery services that seek to reduce patient crowding. 23.
All health center staff are aware on the procedures guidelines and implement accordingly 24.
The Health center has a Triage, staffed with appropriately trained personnel and equipped with necessary equipment and supplies.

25.
Outpatient/client appointment systems are in place for all disciplines provided by the health center. 26.
The Health center has a Liaison and Referral Service guideline that the health facility staff understand and implement 27.
There are sign posts at the compound of the health that directs clients/patients to the desired health service units 28.
The health center has established maternity waiting room fulfilled with essential utilities such as latrine, bathroom, electric power and water Domain 4. MEDICAL RECORDS MANAGMENT 29.
The Health Center utilizes a single, unified registration system for all patients/clients, including outpatients and emergency admissions (if relevant, inpatient) or specialty clinics and also utilizes a Master Patient Index with a single, unique Medical Record Number for each patient. 30.
The Health Center utilizes a paper-based or computer-based system to track where the medical record is located at all times and also uses a standardized and uniform set of forms prepared by the FMOH or RHB to document a complete medical record for patient's/client's care. 31.
The Health Center has medical records management guidelines for proper handling and confidentiality of medical records 32.
The Health Center has orientation and training programs for all medical records personnel to ensure awareness and competency in medical record management procedures Domain 5. PHARMACY SERVICES 33.
The Health Center has a Drug and Therapeutics Committee (DTC) which implements various measures designed to promote the rational, safe and cost-effective use of medicines. 34.
The Health Center has a separate pharmacy department comprising dispensaries and medical store directed by a registered Pharmacist and Pharmacist/Pharmacy technician respectively. 35.
The Health Center has a health facility specific List of Medicines classified by VEN that contains all Drugs, Medical Supplies, consumable-Medical equipment's and Reagents. The List shall be reviewed and updated annually. 36.
The health center has an effective supply chain system for pharmaceuticals, medical equipment and supplies 37.
The health center provides clear and correct prescribed drug information to patients and keep the proper record of the service 38.
The Health Center provides access to drug information to both health care providers and patients in order to optimize drug use. 39.
The Health Center has policies and procedures for identifying and managing drug use problems, including: Identifying and reporting adverse drug reactions, and prescription monitoring 40.
The Health Center has a supply and inventory management system for drugs, medical supplies and consumable equipment approved by the DTC 41.
The Health Center conducts a physical inventory of all pharmaceuticals in the store and each dispensing unit at a minimum once a year. 42.
The Health Center ensures proper and safe disposal of pharmaceutical wastes and expired drugs in line with national guidance. 43.
The health centers pharmacy assists and monitors pharmaceutical management activities at the health posts. 44.
All Units of the pharmacy service have adequate personnel, equipment, premises and facilities required to store drugs, medical supplies and equipment and carry out dispensing, and counselling services. 45.
The health center conducts internal audit twice and external audit once every year on all pharmaceuticals, equipment and supplies Domain 6. LABORATORY SERVICES

46.
Current list of laboratory tests provided by the facility with the price of each test is accessible to all clinical staff and patients. 47.
Does the Laboratory management meet the needs and requirements of customers making the laboratory results are discussed up on and interpreted correctly 48.
Does the Laboratory have adequate number of staff, necessary space, and materials for work? 49.
The laboratory has a logistic management system to monitor the procurement and use of laboratory materials that prevents unnecessary storage or shortage 50.
The laboratory has standard operating procedures(Rejection, transport, retention and disposal) and follows it properly 51.
The laboratory work environment is organized and clean at all times that specimen handling mechanisms ensures safety for the service providers and users 52.
The laboratory have a health and safety manual with procedures that include different types of actions(handling fire and chemical hazard etc.) 53.
The laboratory management prepares an established policy for data and information management on data safety, confidentiality, data storing period and disposal mechanisms 54.
Does the laboratory have and implements a quality assurance policy that covers all aspects of laboratory functions Domain 7. INFECTION PREVENTION SAFETY 55. Infection prevention and patient safety committee is established 56.
Infection prevention and patient safety committee implementation guideline is prepared 57.
Infection prevention and patient safety committee has prepared action plan 58.
Infection prevention and patient safety committee plan vs performance report is reviewed by the health center management body 59.
Major communicable diseases at the health centers are identified 60.
Standard practices to prevent, control and reduce risk of HCAIs are in place and transmission based precautions (TBP) are adequately addressed 61.
Health center infection prevention activity monitoring and implementation is based on routes of infection transmission 62.
The Health center ensures that equipment, supplies and facilities/infrastructure necessary for infection prevention are available. 63.
In order to implement Infection prevention standard and patient safety activities, essential antiseptic and disinfectants are fulfilled in sufficient and appropriate composition 64.
All health center staff are trained using standard infection prevention training materials. 65.
The Health center provides health education to patients, caregivers and visitors, as appropriate on infection prevention practices 66.
Infection prevention and patient safety activities at the health center are also harmonized with the satellite health post and health development groups activity at community level Domain 8. MEDICAL EQUIPMENT MANAGMENT 67. The health center conducts annual inventor and has a paper-based or computer-based inventory management system that tracks all equipment included in the equipment management program. 68.
Health center assigned head of medical equipment technicians accountable to the head of the health center 69.
All new equipment undergoes acceptance testing prior to its initial use to ensure the equipment is in good operating condition. Equipment is installed and commissioned in accordance with the manufacturer's specifications.

70.
All equipment users are appropriately trained on the operation and maintenance of medical equipment with standard operating procedures readily available to the user. All equipment users are trained on emergency and fire accident prevention and control techniques 71.
The health center owns a building plan that is registered by its name, fenced compound, well functioning waste disposal system, toilet and clean and safe and green recreational/garden areas 72.
There is medical equipment and facility engineering administration policy manual /guidance at health center indicating the health center receives Medical equipment maintenance technical support from selected joint coordination bodies such as hospital, regional health bureau or there outsourced institution based on contractual or MOU agreement 73.
For health center medical engineering administration there is a medical equipment maintenance request, opening, closing and reporting formats readily available 74.
The health center established system on use of facility cars with formal entry and exit control at the facility gates 75.
For health center essential health service care, there is 24/7 water and electric power supply or its alternatives 76.
Health center has an advance emergency preparedness and response plan on fire and emergency conditions Domain 9. HUMAN RESOURCE MANAGMENT 77.
Personnel are assigned to provide Human Resource Management services.

78.
Each employee has a personnel file that is maintained by the HRM case team or case worker.

79.
A Human Resource Development plan has been developed 80.
Job descriptions have been adopted and documented for each position at the health center. 81.
Performance evaluation has been made every 6 month for each each employee. 82.
Employee benefits and motivation package developed and implemented. 83.
Standardized uniforms and badges are worn by staff.

Domain 10. PERFORMANCE QUALITY IMPROVEMENT
84. The health center should establish a structure (multidisciplinary team) for performance monitoring and quality improvement 85.
The health center needs to prepare an annual and quarterly plan 86.
The health center needs to implement quality improvement cycle for selected priority problems 87.
The health center needs to collect, analyze and use for quality improvement purposes and report reportable indicators to the respective body as per the HMIS standard 88.
Client satisfaction survey and other quality improvement assessments are conducted, analyzed and applied for quality improvement purposes