title: A systems approach to improving rural care in Ethiopia.
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.
  
  
  RESULTS
  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
  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.
authors.affiliation: Yale School of Public Health, Global Health Leadership Institute, Yale University, New Haven, Connecticut, United States of America. elizabeth.bradley@yale.edu
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
authors.forename: Patrick
authors.initials: P
authors.lastname: Byam
authors.forename: Rachelle
authors.initials: R
authors.lastname: Alpern
authors.forename: Jennifer W
authors.initials: JW
authors.lastname: Thompson
authors.forename: Abraham
authors.initials: A
authors.lastname: Zerihun
authors.forename: Yigeremu
authors.initials: Y
authors.lastname: Abebe
authors.forename: Yigeremu
authors.initials: Y
authors.lastname: Abeb
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Curry
mesh_terms: D003695:Delivery of Health Care / Q000379:methods* / Q000592:standards; D005002:Ethiopia; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008137:Longitudinal Studies; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods / Q000592:standards; D011296:Prenatal Diagnosis / Q000379:methods / Q000592:standards; D011320:Primary Health Care / Q000379:methods* / Q000592:standards; D019035:Rural Health Services / Q000592:standards*