Background
Institutionalizing clinical and administrative guidelines
The ‘theory of change’ in USAID transform: Primary health care project interventions
Methods
Study site
Health tier system calibers
Performance tier
Study design
Performance management and improvement intervention
Sampling
Data collection methods and data quality
Chapter | Description of the indicators & composite criteria considered |
---|---|
Leadership and Governance | This chapter deals with evidence of establishment & functionality of how boards will be scored: i.e. minutes, official assignment; guidelines; term of references; regular board meetings; strategic and annual plans; established functional management committees; review performance of health center directors; post services costs; agreements signed to provide credit services; financial reports using balance sheets; approved purchase plans; financial guidelines; & audit reports. (12 standards and 35 validation criteria). |
Health Center & Health Post Linkage | This chapter deals with scores to measure health center and health post linkages. The standards include, availability of health center and health post linkage guidelines, assigned focal person, agreed action plans with budgets, establishment of women development groups and 1 to 5 network of health development army, facilitation of supportive supervision on a weekly base, monthly capacity enhancement & performance review meetings; and availability of tracer drugs in the health posts. (8 standards with 300 validation criteria) |
Patient Flow & Service Organization | The patient flow and service organization chapter has six standards and 20 validation criteria. The detail of the standards includes: developed protocol and procedures on patient flow, triage, referral and preparations to manage emergency services, training of staff to implement protocols, equipping of liaison officer, telephone facilities, registers, books, referral directory, appointment register, clear labels and/or signage of facilities and services, establishment of maternal homes (waiting area) with full sets of facilities: shower; toilets; kitchen etc. (6 standards with 20 validation criteria) |
Medical Records Management | The medical records management chapter deals with the establishment of a well-organized archive room, institutionalization of unique patient identifiers, establishment of digital or manual index and availability of essential resources like cards forms, printed sheets, confidentiality of patient information through protocol and process, compliance officers, creating staff awareness on developed processes and arrange experience sharing event. (4 standards with 9 validation criteria) |
Pharmacy Services | The pharmacy service chapter is designed to meet the primary needs of all customers. The detail criteria include establishment of a drug and therapeutic committee with Term of References, developed annual plan, testimony with minutes and reports, pharmacy department led by a pharmacist and store managed by a diploma level pharmacy technician, development of facility level drug list using VEN categorization, forecasting, purchasing & disposal guidelines, dispensing of drugs after recording detailed information of patients and drugs, establishment of a drug information center, protocol for management of side effects and other problems, use of logistics management tools, inventory of drugs and disposal guidelines, availability of tracer drugs in health posts, preparation of standard rooms and an audit report. (13 standards with 21 validation criteria) |
Laboratory Services | This chapter deals with provision of laboratory services. Some of the standards refer to public information availibility about the services, time, and costs, counseling services with clients to understand the meaning of the investigations & results, preparation of adequate rooms, assignment of human resources and supplies as per the requirements and standards, institutionalization of laboratory operating management systems, availability of standard operating procedures (SOP) on sample collection, transport; storing & disposals, safety procedures, diagnostic algorisms, laboratory information systems, maintenance procedures of lab equipment, safety procedures in place, e.g. fire extinguisher and trained staff on safety, data safety & confidentiality, internal quality control and participation in External Quality Assurance.(9 standards with 23 validation criteria) |
Clean, and Safe Health Facility | These standards measure the health facility’s engagement and dedication to providing services in a clean, safe and healthy environment, assignment of a focal person to facilitate technical support to all staff, allocation of budget, institutionalization of a functional infection prevention committee i.e. minutes, action plan and feedback, and availability of personal protective equipment, soaps; detergents; mops and hand tools to prepare land for gardening, support to health posts in implementing standard infection principles in their facilities, all staff training on infection prevention, health education to clients and patients on infection preventions, following of procedures of waste management, and adherence to medical instrument decontamination and sterilization procedures. (10 standards with 13 validation criteria) |
Medical Equipment Management & Biomedical Engineering | The biomedical engineering chapter deals with the availability of functional medical equipment in the health facilities., Some of the standards are: inventory of medical equipment, functionality of new equipment, orientation to staff on use and care new equipment, prepare maintain request forms, maintenance of equipment, functionality and safety of medical equipment, availability of water and electricity supply i 24 h a day/seven days week. (8 standards with 40 validation criteria) |
Human Resources Management | The human resource chapter deals with human resource management and development. The standards are; availability of human resource personnel, archiving of personal files with JD, employment letter and other testimonies, human resource development plan, establishment of motivation and reward systems, appraisal of the performance of health workforce every six months, use uniform and Identification cards for all staff. (6 standards with 8 validation criteria) |
Quality Improvement and Health Information System | This chapter deals with quality improvement and complies with the routine Health Information System requirements. The standards are: establishment of quality improvement team, (minutes, Term of References), sharing of work plan to departments and staff aggregated by weeks months and quarters, implementation of quality improvement tools in selected health services i.e. problem-solving tools, adherence to routine health information system requirements timely, complete and consistent report submission and use of data for decision making, engagement of the community towards quality improvement and completion of client satisfaction and other surveys. (5 standards with 10 validation criteria) |
Data analysis
Ethical clearance
Results
Distribution of districts with primary health care units
Zone | Number of Woredas | Proportion | Number of Health Centers | Proportion |
---|---|---|---|---|
Awi Zone | 2 | 3% | 10 | 2% |
Wag-Himira | 5 | 7% | 23 | 5% |
Oromia | 6 | 8% | 26 | 6% |
East Gojjam | 6 | 8% | 32 | 7% |
North Shoa | 10 | 13% | 38 | 9% |
South Gondar | 6 | 8% | 52 | 12% |
West Gojjam | 8 | 11% | 57 | 13% |
Gondar | 10 | 13% | 59 | 13% |
North Wollo | 9 | 12% | 62 | 14% |
South Wollo | 14 | 18% | 84 | 19% |
Total | 76 | 100% | 443 | 100% |
Socio-demographic background of trained health professionals
Characteristics | Frequency | Percent (%) |
---|---|---|
Sex | ||
Male | 1099 | 84.1% |
Female | 207 | 15.9% |
Total | 1306 | 100% |
Professions | ||
BSc in Midwifery Nursing | 5 | 0.4% |
Pharmacist (B Pharm) | 6 | 0.4% |
Diploma Pharmacy Technicians | 26 | 2.0% |
BSc in Environmental Health Officers | 31 | 2.4% |
Master’s in public health | 38 | 2.9% |
Diploma Medical Laboratory Technicians | 46 | 3.5% |
Diploma in Midwifery Nursing | 50 | 3.8% |
BSc Nurses | 101 | 7.7% |
Public Health Officers | 264 | 20.2% |
Diploma Nurses | 344 | 26.4% |
Health Information Technicians | 395 | 30.2% |
Total | 1306 | 100% |
Changes in EHCRIG standard performances
Changes in district health system performance
Variables | Mean Score (%) ± SD | Minimum Score (%) | Maximum Score (%) |
---|---|---|---|
First Score (baseline) | 59 ± 11.86 | 35 | 89 |
Second Score | 66 ± 12.12 | 36 | 90 |
Difference between first and second validation measurement score | 7 (t = −7.15, df = 75, P = 0.000), r = 0.74 |
Performance tier & number of Woredas | Mean | SD | Std. Error | 95% Confidence Interval for Mean | Minimum | Maximum | |
---|---|---|---|---|---|---|---|
Lower Bound | Upper Bound | ||||||
High (10) | 74.3 | 10.7 | 3.4 | 66.6 | 82.0 | 60.0 | 90.0 |
Medium (23) | 66.0 | 12.0 | 2.5 | 60.8 | 71.2 | 44.0 | 85.0 |
Low (43) | 65.2 | 12.1 | 1.8 | 61.5 | 68.9 | 36.0 | 89.0 |
Total (76) | 66.6 | 12.1 | 1.4 | 63.9 | 69.4 | 36.0 | 90.0 |
Source of Variances | Sum of Squares | df | Mean Square | F | Sig. | |
---|---|---|---|---|---|---|
Woreda (district) performance tier | Between Groups | 680.9 | 2 | 340.4 | 2.4 | 0.09 |
Within Groups | 10,350.0 | 73 | 141.8 | – | – | |
Total | 11,030.9 | 75 | – | – | – |