Background: Avante Zambézia is an initiative of a Non-Governmental Organization (NGO), Friends in Global Health, LLC (FGH) and the Vanderbilt Institute for Global Health (VIGH) to provide technical assistance to the Mozambican Ministry of Health (MoH) in rural Zambézia Province. Avante Zambézia developed a district level Health Management Mentorship (HMM) program to strengthen health systems in ten of Zambézia's 17 districts. Our objective was to preliminarily analyze changes in four domains of health system capacity after the HMM's first year: accounting, Human Resources (HRs), Monitoring and Evaluation (M&E), and transportation management. Methods: Quantitative metrics were developed in each domain. During district visits for weeklong, on-site mentoring, the health management mentoring teams documented each indicator as a success ratio percentage. We analyzed data using linear regressions of each indicator's mean success ratio across all districts submitting a report over time. Results: Of the four domains, district performance in the accounting domain was the strongest and most sustained. Linear regressions of mean monthly compliance for HR objectives indicated improvement in three of six mean success ratios. The M&E capacity domain showed the least overall improvement. The one indicator analyzed for transportation management suggested progress. Conclusion: Our outcome evaluation demonstrates improvement in health system performance during a HMM initiative. Evaluating which elements of our mentoring program are succeeding in strengthening district level health systems is vital in preparing to transition fiscal and managerial responsibility to local authorities. Implications for policy makers• Health worker shortages and weak health systems threaten to undermine the ability to attain key health goals. • A strategy to deploy teams of mentors to build capacity by equipping district health managers with skills in planning, priority setting, and problem solving across eight target health management domains was implemented with some early success. • Mutual trust stemming from an open and collaborative relationship with provincial and district health authorities was key to program success. •In following best practice guidelines in global health by involving local stakeholders, our interventions were designed to target areas of joint priority and need, which encourages both relevance and sustainability of the program. This is particularly important as President's Emergency Plan for AIDS Relief (PEPFAR) seeks to fully transition authority to local entities, though we recognize that such a process can have precarious consequences if done too quickly or too cheaply. Implications for publicA health management mentoring initiative was implemented as part of a larger President's Emergency Plan for AIDS Relief-funded (PEPFARfunded) HIV care and treatment scale-up program, based on assumptions that improvements in overall system performance will eventually result in better clinical outcomes for patients. Our result...