BackgroundMultiple 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.Methodology/Principal FindingsWe 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/SignificanceEffective 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.

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.

Main ObjectiveFew studies have examined the long-term, impact of large-scale interventions to strengthen primary care services for women and children in rural, low-income settings. We evaluated the impact of the Ethiopian Millennium Rural Initiative (EMRI), an 18-month systems-based intervention to improve the performance of 30 primary health care units in rural areas of Ethiopia.MethodsWe assessed the impact of EMRI on maternal and child survival using The Lives Saved Tool (LiST), Demography (DemProj) and AIDS Impact Model (AIM) tools in Spectrum software, inputting monthly data on 6 indicators 1) antenatal coverage (ANC), 2) skilled birth attendance coverage (SBA), 3) post-natal coverage (PNC), 4) HIV testing during ANC, 5) measles vaccination coverage, and 6) pentavalent 3 vaccination coverages. We calculated a cost-benefit ratio of the EMRI program including lives saved during implementation and lives saved during implementation and 5 year follow-up.ResultsA total of 134 lives (all children) were estimated to have been saved due to the EMRI interventions during the 18-month intervention in 30 health centers and their catchment areas, with an estimated additional 852 lives (820 children and 2 adults) saved during the 5-year post-EMRI period. For the 18-month intervention period, EMRI cost $37,313 per life saved ($42,366 per life if evaluation costs are included). Calculated over the 18-month intervention plus 5 years post-intervention, EMRI cost $5,875 per life saved ($6,671 per life if evaluation costs are included). The cost effectiveness of EMRI improves substantially if the performance achieved during the 18 months of the EMRI intervention is sustained for 5 years. Scaling up EMRI to operate for 5 years across the 4 major regions of Ethiopia could save as many as 34,908 lives.SignificanceA systems-based approach to improving primary care in low-income settings can have transformational impact on lives saved and be cost-effective.

Government-community partnerships are central to developing effective, sustainable models of primary health care in low-income countries; however, evidence about the nature of partnerships lacks the perspective of community members. Our objective was to characterise community perspectives regarding the respective roles and responsibilities of government and the community in efforts to strengthen primary health care in low-income settings. We conducted a qualitative study using focus groups (n=14 groups in each of seven primary health care units in Amhara and Oromia, Ethiopia, with a total of 140 participants) in the context of the Ethiopian Millennium Rural Initiative. Results indicated that community members defined important roles and responsibilities for both communities and governments. Community roles included promoting recommended health behaviours; influencing social norms regarding health; and contributing resources as feasible. Government roles included implementing oversight of health centres; providing human resources, infrastructure, equipment, medication and supplies; and demonstrating support for community health workers, who are seen as central to the rural health system. Renewed efforts in health system strengthening highlight the importance of community participation in initiatives to improve primary health care in rural settings. Community perspectives provide critical insights to defining, implementing and sustaining partnerships in these settings.

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.Methodology/Principal Findings: 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/Significance: 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.