title: Access and quality of rural healthcare: Ethiopian Millennium Rural Initiative.
abstract: OBJECTIVE
  More than half the world's population lives in rural areas; however, we have limited evidence about how to strengthen rural healthcare services. We sought to determine the impact of a systems-based approach to improving rural care, the Ethiopian Millennium Rural Initiative, on key healthcare services indicators.
  
  
  METHODS
  We conducted an 18-month longitudinal mixed methods study of the 10 primary healthcare units (PHCUs) serving ~400,000 people, using monthly indicator tracking and focus groups.
  
  
  METHODS
  Rural Ethiopia.
  
  
  METHODS
  Ten PHCUs and 140 focus group participants.
  
  
  METHODS
  The Ethiopian Millennium Rural Initiative.
  
  
  METHODS
  Antenatal care coverage, skilled birth attendant rates, HIV testing in antenatal care, HIV testing in the health center or at health posts overall, outpatient volume at the health center. Qualitative data assessed community members' perceptions of healthcare services.
  
  
  RESULTS
  We found significant increases (P-values of <0.05) in antenatal care coverage, skilled birth attendant rates, HIV testing in antenatal care and HIV testing at health center and health post levels. Outpatient visit rates also improved, but the change was not significant. Focus group data suggested that communities recognized substantial improvements but also voiced continued unmet needs.
  
  
  CONCLUSIONS
  A systems-based approach to strengthening rural healthcare units is feasible, although complex, particularly in rural settings. The combined use of quantitative and qualitative data is needed to provide a comprehensive view of impact. Future research is needed to understand the determinants of variation in improvement across health centers and regions.
authors.affiliation: Yale School of Public Health, PO BOX 208034, New Haven, CT 06520-8034, USA. elizabeth.bradley@yale.edu
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Bradley
authors.forename: Jennifer W
authors.initials: JW
authors.lastname: Thompson
authors.forename: Patrick
authors.initials: P
authors.lastname: Byam
authors.forename: Tashonna R
authors.initials: TR
authors.lastname: Webster
authors.forename: Abraham
authors.initials: A
authors.lastname: Zerihun
authors.forename: Rachelle
authors.initials: R
authors.lastname: Alpern
authors.forename: Jeph
authors.initials: J
authors.lastname: Herrin
authors.forename: Yigeremu
authors.initials: Y
authors.lastname: Abebe
authors.forename: Leslie
authors.initials: L
authors.lastname: Curry
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003151:Community Health Centers / Q000706:statistics & numerical data; D003695:Delivery of Health Care; D036861:Delivery, Obstetric; D005002:Ethiopia; D005260:Female; D015658:HIV Infections / Q000175:diagnosis; D006297:Health Services Accessibility / Q000592:standards / Q000639:trends; D006301:Health Services Needs and Demand; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011181:Postnatal Care; D011295:Prenatal Care; D011787:Quality of Health Care / Q000592:standards / Q000639:trends; D012424:Rural Population; D055815:Young Adult