Efficiency of the health extension programme in Tigray, Ethiopia: a data envelopment analysis

Abstract

BackgroundSince 2004, the government of Ethiopia has made a bold decision to strengthen and expand its primary health care system by launching the Health Extension Program (HEP). While the scaling up of the HEP is necessary to achieve the aim of universal access to primary health care, close attention should be paid to the performance of the program. Using a data envelopment analysis this study aimed at (i) to estimate the technical efficiency of a sample of health posts in rural Tigray, ii) to identify those factors which might be explaining the efficiency results.MethodsEfficiency was measured using a data envelopment analysis model. A Tobit model was performed to identify factors associated with efficiency. Seven rural districts (out of 35) were purposely chosen. Input/output information was collected from the database of the Tigray Health Bureau during July 2007-June 2008. Information was also collected on environmental factors that might influence the efficiency outcomes through a structured questionnaire from the correspondent district health officers.ResultsAnalysis was based on data from 60 health posts. The mean scores for technical and scale efficiency were 0.57 (SD = 0.32) and 0.95 (SD = 0.11) respectively. Out of the 60 health posts, 15 (25.0%) were found to be technically efficient constituting the best practice frontier. Thirty eight (63.3%) were operating at their most productive scale size. In the regression analysis, none of the variables was significantly associated with the efficiency outcome.ConclusionThere is a need to review the management of the health information system in the region. The findings have also revealed that only a quarter of the health posts are working efficiently and pointed the need for improvement. A closer monitoring of the health extension programme is required in order to achieve the best possible performance.

Use of Balanced Scorecard Methodology for Performance Measurement of the Health Extension Program in Ethiopia

“…Despite encouraging reports of positive impact of HEP, 8,[22][23][24][25][26]52 the findings of this study show major deficiency in its overall performance. The scores across all domains were low, which could be due to their interdependence, where the capacity for service provision and financial systems influence the human resource development, the community engagement and service provision process that in turn affect the output and outcome dimension.…”

“…6,32,39 Although it used few indicators, a study by Sebastian and others found that the performance of HEP was poor and that there was inefficiency in productivity relative to available resources, which is an indication that multidimensional factors other than inputs affect the outcome of the program. 8 The BSC approach used in this article helped identify health system elements with relatively poor performance. 14,16 The performance of the program was low in the areas of infrastructure, commodity (including financing, distribution and availability), satisfaction and perception of HEWs, infection prevention, referral linkage, and service quality and outputs.…”

“…6 It is therefore imperative that HEP should be evaluated to determine whether its objectives are being achieved and to document factors that facilitate or hinder the realization of the objectives. 7,8 This requires comprehensive measures that provide evidence on performance of a range of health system elements for decision makers while also promoting good governance and accountability.…”

“…HEP is one of the core components of HSDP, and although studies have documented the performance of the program on individual indicators, [22][23][24][25][26] there is limited evidence on integrated performance indices and scoring methodologies. 8 We developed a scoring methodology for performance evaluation of HEP based on the BSC approach 14,21 and generated performance indices using data obtained from nationwide HEP evaluation survey. It compared performance of various geographic areas and identified health system elements …”

Provision of injectable contraceptives in Ethiopia through community-based reproductive health agents

“…In 2003, the Government of Ethiopia launched the Health Extension Programme to develop a body of salaried basic-level health-care providers -health extension workers (HEWs) -who could increase the availability and coverage of basic health services for Ethiopia's large rural population. 22,23 While HEWs have been an innovative addition to the Ethiopian health sector, their ability to conduct community outreach varies depending on the time demanded by the wide range of health interventions for which they are responsible. Another group of workers composed of volunteers known as community-based reproductive health agents (CBRHAs) was initially mobilized to provide basic family planning services and referrals, although they have acquired more responsibilities in the community and often support the activities of the HEWs.…”