A Systems Approach to Improving Rural Care in Ethiopia

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

doi:10.1371/journal.pone.0035042

Elizabeth H Bradley, Jennifer W Thompson + Show 6 more

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https://doi.org/10.1371/journal.pone.0035042

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Journal: PloS one	Publication Date: Apr 25, 2012
Citations: 80	License type: CC BY 4.0

Affiliation: Yale University, International Trachoma Initiative

Abstract

BackgroundMultiple 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 FindingsWe 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/SignificanceEffective 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.

Highlights

Improving access to and quality of rural primary health care, especially in low-income settings, is a global priority [1,2]
We found similar challenges across all 7 primary health care units (PHCUs) in their reports of rough geographic terrain and long distances to services, inadequate financial budgets, and cultural norms that made individuals hesitant to use formal health services, differences across the PHCUs in the themes related to problem solving at the facility level, relationships with the woreda health office, and community engagement with health issues were prominent
We found several key themes that distinguished consistently higher performing PHCUs from those that had shown the most improvement and those that were consistently lower performing

Summary

Introduction

Improving access to and quality of rural primary health care, especially in low-income settings, is a global priority [1,2]. Prior research has identified the cost, level and quality of available health services [7,13,14], distance and transportation [14,15,16], and social and cultural norms [17,18] as site-level factors influencing the utilization of primary health care services This literature is useful, studies typically report overall effects, limiting our understanding of the heterogeneity in effects across different intervention sites even within the same study. Multiple interventions have been launched to improve the quality, access, and utilization of primary health care in rural, low-income settings; the success of these interventions varies substantially, even within single studies where the measured impact of interventions differs across sites, centers, and regions. 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

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