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A Systems Approach to Improving Rural Care in Ethiopia

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  • Elizabeth H Bradley
  • Patrick Byam
  • Rachelle Alpern
  • Jennifer W Thompson
  • Abraham Zerihun
  • Yigeremu Abeb
  • Leslie A Curry

Abstract

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.

Suggested Citation

  • Elizabeth H Bradley & Patrick Byam & Rachelle Alpern & Jennifer W Thompson & Abraham Zerihun & Yigeremu Abeb & Leslie A Curry, 2012. "A Systems Approach to Improving Rural Care in Ethiopia," PLOS ONE, Public Library of Science, vol. 7(4), pages 1-7, April.
  • Handle: RePEc:plo:pone00:0035042
    DOI: 10.1371/journal.pone.0035042
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    References listed on IDEAS

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    1. Jane Griffin, 1996. "The Future of Primary Care," Monograph 000418, Office of Health Economics.
    2. Gage, Anastasia J., 2007. "Barriers to the utilization of maternal health care in rural Mali," Social Science & Medicine, Elsevier, vol. 65(8), pages 1666-1682, October.
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    1. Abate, Gashaw T. & Dereje, Mekdim & Hirvonen, Kalle & Minten, Bart, 2020. "Geography of public service delivery in rural Ethiopia," World Development, Elsevier, vol. 136(C).
    2. Eric von Hippel & Georg von Krogh, 2016. "CROSSROADS—Identifying Viable “Need–Solution Pairs”: Problem Solving Without Problem Formulation," Organization Science, INFORMS, vol. 27(1), pages 207-221, February.
    3. Misganaw Teshager Abeje & Atsushi Tsunekawa & Nigussie Haregeweyn & Zemen Ayalew & Zerihun Nigussie & Daregot Berihun & Enyew Adgo & Asres Elias, 2020. "Multidimensional Poverty and Inequality: Insights from the Upper Blue Nile Basin, Ethiopia," Social Indicators Research: An International and Interdisciplinary Journal for Quality-of-Life Measurement, Springer, vol. 149(2), pages 585-611, June.
    4. Lewis, Todd P. & Aryal, Amit & Mehata, Suresh & Thapa, Astha & Yousafzai, Aisha K. & Kruk, Margaret E., 2022. "Best and worst performing health facilities: A positive deviance analysis of perceived drivers of primary care performance in Nepal," Social Science & Medicine, Elsevier, vol. 309(C).
    5. Netsanet Fetene & Erika Linnander & Binyam Fekadu & Hibret Alemu & Halima Omer & Maureen Canavan & Janna Smith & Peter Berman & Elizabeth Bradley, 2016. "The Ethiopian Health Extension Program and Variation in Health Systems Performance: What Matters?," PLOS ONE, Public Library of Science, vol. 11(5), pages 1-19, May.
    6. Leslie A Curry & Patrick Byam & Erika Linnander & Kyeen M Andersson & Yigeremu Abebe & Abraham Zerihun & Jennifer W Thompson & Elizabeth H Bradley, 2013. "Evaluation of the Ethiopian Millennium Rural Initiative: Impact on Mortality and Cost-Effectiveness," PLOS ONE, Public Library of Science, vol. 8(11), pages 1-6, November.
    7. Timothy Powell-Jackson & Jessica J C King & Christina Makungu & Matthew Quaife & Catherine Goodman, 2023. "Management Practices and Quality of Care: Evidence from the Private Health Care Sector in Tanzania," The Economic Journal, Royal Economic Society, vol. 134(657), pages 436-456.
    8. Anne Christine Stender Heerdegen & Moses Aikins & Samuel Amon & Samuel Agyei Agyemang & Kaspar Wyss, 2020. "Managerial capacity among district health managers and its association with district performance: A comparative descriptive study of six districts in the Eastern Region of Ghana," PLOS ONE, Public Library of Science, vol. 15(1), pages 1-18, January.

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