title: The Ethiopian Health Extension Program and Variation in Health Systems Performance: What Matters?
abstract: BACKGROUND
  Primary health care services are fundamental to improving health and health equity, particularly in the context of low and middle-income settings where resources are scarce. During the past decade, Ethiopia undertook an ambitious investment in primary health care known as the Ethiopian Health Extension Program that recorded impressive gains in several health outcomes. Despite this progress, substantial disparities in health outcomes persist across the country. The objective of this study was to understand how variation in the implementation of the primary health care efforts may explain differences in key health outcomes.
  
  
  RESULTS
  We conducted a qualitative study of higher-performing and lower-performing woredas using site visits and in-depth interviews undertaken in 7 woredas. We classified woredas as higher-performing or lower-performing based on data on 5 indicators. We conducted a total of 94 open-ended interviews; 12-15 from each woreda. The data were analyzed using the constant comparative method of qualitative data analysis. Substantial contrasts were apparent between higher-performing and lower-performing woredas in use of data for problem solving and performance improvement; collaboration and respectful relationships among health extension workers, community members, and health center staff; and coordination between the woreda health office and higher-level regulatory and financing bodies at the zonal and regional levels. We found similarities in what was reported to motivate or demotivate health extension workers and other staff. Additionally, higher-performing and lower-performing woredas shared concerns about hospitals being isolated from health centers and health posts. Participants from both woredas also highlighted a mismatch between the urban health extension program design and the urban-dwelling communities' expectations for primary health care.
  
  
  CONCLUSIONS
  Data-informed problem solving, respectful and supportive relationships with the community, and strong support from zonal and regional health bureaus contributed to woreda performance, suggesting avenues for achieving higher performance in primary health care.
authors.affiliation: Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America.
authors.forename: Netsanet
authors.initials: N
authors.lastname: Fetene
authors.affiliation: Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America.
authors.forename: Erika
authors.initials: E
authors.lastname: Linnander
authors.affiliation: JSI Research and Training Institute, Inc., Boston, MA, United States of America.
authors.forename: Binyam
authors.initials: B
authors.lastname: Fekadu
authors.affiliation: Harvard School of Public Health, Boston, MA, United States of America.
authors.forename: Hibret
authors.initials: H
authors.lastname: Alemu
authors.affiliation: Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America.
authors.forename: Halima
authors.initials: H
authors.lastname: Omer
authors.affiliation: Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America.
authors.forename: Maureen
authors.initials: M
authors.lastname: Canavan
authors.affiliation: Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America.
authors.forename: Janna
authors.initials: J
authors.lastname: Smith
authors.affiliation: Harvard School of Public Health, Boston, MA, United States of America.
authors.forename: Peter
authors.initials: P
authors.lastname: Berman
authors.affiliation: Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Bradley
mesh_terms: D003695:Delivery of Health Care; D005002:Ethiopia; D005260:Female; D006801:Humans; D008297:Male; D009313:National Health Programs; D011320:Primary Health Care