Descriptions of positive changes.

Participants from both higher- and lower-performing sites described positive changes in their communities associated with the health extension program. This finding was apparent across rural and urban settings, and distance from major towns did not seem to influence the experience. Participants gave detailed and meaningful examples, especially related to hygiene and environmental sanitation. As community members from both lower and higher performing sites described:

Today there is nobody who don’t have latrine, [we do] it by educating and by inspiring. We have learnt to teach, in order to make nobody defecate in the field” (Health development army member; higher-performing, rural; P33, W2)

We are changing ourselves, our children and our environment with the education they are giving us. In the past, only those who had some education and awareness were digging garbage pits and latrines. Nowadays, following the education they [HEWs] provide at the lower levels, we dig garbage pits and latrines separately. They come to our neighborhood and teach us where to burn dry garbage and where to dump the wet one…I can say that I have gained strong awareness from them. (Health development army member; lower-performing, urban; P30, W4)

In addition to experiencing improvements, people interviewed in both higher-performing and lower-performing primary health care units described impressive cross-sectoral investments and collaborations that were undertaken in a collaborative, complementary way. Several participants reflected that agriculture and education were viewed as contributing to the health goals of the community, as described by a woreda health office head in a higher-performing woreda.

The education sector also has responsibilities like educating children about pregnancy follow up, immunization and so on and so forth through education awareness will be created in schools. Moreover, in the agriculture sector it will enable the community to eat a balanced diet; this is one package of the health sector…there is [also] what we call ‘protein corn.’ This means it is a corn that is rich in protein. Therefore, if the farmer produces and uses this protein corn, then the farmer has gotten protein. (Woreda health office head; higher-performing, rural; P9, W2)

People interviewed highlighted that health would be achieved most effectively through contributions from different sectors in a holistic approach instead of the health sector working independently. Collaborating with non-health sectors was viewed as central to the woreda health office’s work.

We do not say this concerns me, you, or this belongs to health or to agriculture and so on. Since the kebele’s activities are evaluated as a structured-whole, focusing on this activity or that [activity] alone is not enough to achieve our goals. (Health center director; lower-performing, rural; P3, W5)

Contrasts between higher- and lower-performing woredas.

Despite some common experiences, substantial contrasts were apparent between higher-performing and lower-performing woredas, and these differences were pertinent in both urban and rural settings. Prominent among these contrasts were the 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 zonal and regional health bureaus.

Use of data for problem solving and performance improvement: People interviewed from higher-performing primary health care units reported the active use of data for problem solving, and the use of root cause analyses as a foundation for continuous improvement efforts. Feedback, planning, and supportive supervision emerged as important aspects of project work, as described by a health extension worker supervisor in a higher-performing rural woredas:

We bring the [evaluation] findings to the health center after the supervision. We sit with the head of the health center and discuss the [ones who have achieved the] best performances and identify gaps. Our main principle is to make the best performances continue. In addition, we discuss why the gaps were created and how we are going to correct them. We develop feedback on how the work should proceed; then we try to reach a consensus with the health extension workers. (Health extension worker supervisor; higher-performing, rural; P6, W2)

In some examples, problem solving in higher-performing woredas involved learning from other regions, as described by a health center director from a higher-performing urban woreda:

In the past, mothers used to be sent home if they were diagnosed to have false labor and the real thing happens while they were at home and they deliver there. To tackle such problem we have adopted what the Tigray region is already doing that is we have waiting area for those diagnosed false labor. In this waiting area there is coffee ceremony, porridge and oatmeal will be prepared there while she is being followed. This has created a sense of home environment and a feeling of being among family. The mothers stay till they give birth here. (Health center director; higher-performing, urban; P24, W7)

Moreover, people interviewed in higher-performing woredas remarked on routine procedures used to improve workers’ performance. These included data monitoring and feedback, recognizing good performance, and teaching others about what they viewed as best practices or ideas worth scaling up. A woreda administrator from higher-performing rural woreda said:

There is a command post evaluation meeting with the zonal leaders once or twice a week. There is a feedback session during the planning phase [to see] if the planning is exaggerated or under planned. During mid-term evaluations, [zonal leaders] attend the sessions and give us their constructive comments. In addition, they do the field assessments. During the field assessment visits, they crosscheck our reports with the actual activity on the ground. Basing the comments from the zone, if there are gaps, then we will fill those gaps together. And if there are best practices, we will try to illuminate them more. (Woreda administrator; higher-performing, rural; P8, W2)

Supervisors across administrative levels in higher-performing woredas reported using checklists to monitor employee trainings and performance. The process for supervision was described as follows in one higher-performing rural woreda:

For each kebele [health post], professionals are assigned from the health center. There are specific days that they provide supports. This is listed; based on this [schedule] they go and provide the needed support and come back. There is a checklist prepared by the health center and they will support based on the list of the activities on the checklist. The professionals will stay all day providing support, assessing what has been done, solving the challenges faced, and making discussion on the findings. In addition, we [the health center] evaluate the overall work of HEW every month. (Health extension worker supervisor; higher-performing, rural; P6, W2)

In contrast, lower-performing woredas struggled to have high quality data reports. Participants described that they lacked the resources needed to collect timely and accurate data (e.g., limited information technology, limited educational background on data collection and reporting). Additionally, participants underscored the irregularities of reporting, suggesting that even if data were collected accurately, it was not always reported consistently.

What disappoints me firstly is a false report. There is a wrong evaluation given sometimes and false statement is presented without being filtered. There are instances whereby the institution and individuals are wrongly awarded. Some even add up false figures to state the prevention of epidemic or other work but as a person who has been on the task for many years I know when false figures are reported. (Zonal health department head; lower-performing, rural; P85, W5)

Furthermore, when reports and data were available, the data were not always used for learning, problem solving, and performance improvement. The focus was on being sure reporting requirements to the woreda were met without understanding that such data could be a powerful tool for inclusive performance improvement efforts at the woreda-level primary health care system overall. Woreda officials were described as requested data directly from health extension workers and bypassing the HMIS focal person at health center, resulting in missed opportunities for evidence-based problem solving and collaboration:

Sometimes conflicts arise when you strive to maintain regulations and procedures. For instance there is a report we file every 15 days or every month and the woredas cut you out and take the report from health extension [workers] when you ask them to uphold the procedure. The health extension [worker] is afraid of the woreda officials and therefore they give them their reports. Their report is therefore not available at the health centers but it is there with the woreda and the zone; the zone later comes back to you for evaluation and asks you to present that report which we don’t have. (Health extension worker supervisor; lower-performing, urban; P36, W4)

Relationships between health centers, health extension workers, and community: Staff and community members in higher-performing PHCUs described effective collaboration among the health extension workers, kebele councils, health centers, and health development armies. In higher-performing woredas, health extension workers described being supported by the community with needed materials and resources:

If there is a job that needs to be done in the community we first discuss and reach on consensus with the community members. We will say that we plan to do this and this activities, and we want you to help us in terms of manpower, resource and money. Then they help us. (Health extension worker; higher-performing, rural; P6, W2)

Furthermore, health extension workers in higher-performing woredas reported feeling respected and listened to by the community, as suggested in the following statement from a health extension worker in a higher-performing woreda:

The people in my site…usually welcome me into their home and offer me cup of tea or coffee. It is only sometimes that I face people who resist my service and my persistence win them over through continuous visiting, involving other members of the community to convince them and giving them brochures and fliers for them to read…I’m continuously following them up. (Health extension worker; higher-performing, urban; P45, W7)

In contrast, people in lower-performing woredas reported conflict arising in their everyday work, reflecting strained relationships with the community and with other health professionals. Commenting on the poor relationships with the community, one health extension worker from a lower-performing, rural woreda described:

When we get to their homes and tell them to maintain sanitation, there are some people accusing us of trespassing and entering a private property without court order; they may also attempt to beat you up. What you must do here is that you must be polite enough to talk to them and convince them as this challenge may come again tomorrow. (Health extension worker; lower-performing, rural; P36, W4)

Woreda officials and health extension workers in lower-performing woredas also reflected on the prominence of traditional practices and cultural norms that challenged the relationships between the community and the health extension workers.

There is a lack of understanding with the society in terms of prevention as the awareness was dominated by the traditional practices that prevailed for centuries with the society. For instance they don’t take pregnant women to heath facilities for follow-up and delivery as they insist to give birth at home. Also concerning toilets and sanitation, there is a trend of not quickly getting used to a new approach by quitting the old tradition. (Woreda administrator; lower-performing, rural; P82, W6)

Coordination and support from the higher-level regulatory and financing bodies: In higher-performing woredas, the woreda health office generally described the relationship and support from the zonal or regional health offices as effective. Support included transparent communications about budget decisions, new standards or protocols, and performance expectations. Supervision was seen as regular and supportive with collaboration on improvement efforts, such as reducing vacancies, enhancing transportation resources, or ongoing training of staff. As one zonal-level health officer described the support from the region to an urban woreda,

We communicate our needs and the regional health bureau leads these [efforts], training health professionals and health extension workers and also organizing the health facilities. It provides manuals and guidelines and conducts capacity building works by allocating full budget for training. It also provides follow up and…the review is all inclusive. The regional health bureau facilitates health extension festivals… (Health officer; higher-performing, urban; P71, W1)

Such support was apparent in the descriptions of the support from the regional and zonal levels for higher-performing rural woredas as well. In the rural woredas, support for planning and evaluation of performance as well as filling gaps in capacity of primary health care personnel were highlighted as critical inputs. One health officer who worked to link the zone and the woreda described the support from the region,

The region makes all types of support. The first is technical support starting from planning. The other one is closing part in which every activity of health care services are evaluated in the presence of different professionals or management bodies from the district and the zone. These supports cover all segments of our activities to fill skill gaps, provide trainings, and provide input supports. [The regional health bureau people] go to health post and household level and evaluate what is done. This is a very impressive act of inspection and evaluation. Lastly they discuss the findings…and [provide] malaria prevention support, diagnosis kits, medical furniture, and diagnosis utensils. (Health officer; higher-performing, rural; P78, W3)

In contrast, relationships between the woreda-level and higher zonal and regional levels were described as distant, with little contact between focal persons working at each of the administrative levels. One zonal coordinator from lower-performing rural woreda expressed the stressfulness of poor relationships.

Sometimes when you do good work but you are told otherwise; it disrupts the peaceful work conditions…It [is] a disappointment and discomfort when your superior is simply angry with you at your work without understanding the reasons…a work leader who gives morale to work together is really encouraging for me. Personally I think it is better to be invited and encouraged to work together instead of being given an order to do some job. (Zonal health extension program coordinator; lower-performing, rural; P62, W5)

Similarly, a Health Management Information System (HMIS) focal person from lower-performing urban woreda described feelings of the woreda and kebele levels being abandoned or forgotten by higher levels:

Whenever directions are sent from [the regional health] bureau, they just leave it at zone level; they do not take it down. For example, we heard when we went to ask our salaries that there are some directions sent recently. Let me tell you by relating them. When we ask them, they tell us that it has already come. They say, “Here it is,” but they do not give it to you. They tell you, “Here it is,” but it has no elaboration. They don’t give you the information properly and clearly. There the guidelines are, the directions that concern us, but they conceal them from us. (HMIS focal person; lower performing, urban; P20, W4)

Similarities across higher-performing and lower-performing woredas.

We found similarities in what was reported to motivate or demotivate health extension workers and other staff, although motivating factors were more prominent in the higher-performing woredas. Additionally, higher-performing and lower-performing woredas shared concerns about hospitals being isolated from health centers and health posts. Participants in both higher-performing and lower-performing woredas also highlighted a mismatch between the health extension worker preparation and the urban-dwelling communities’ expectations for primary health care.

Motivation of health workers: In both higher-performing and lower-performing primary health care units, healthcare workers were motivated by the pride and pleasure of helping patients and serving community members. People recalled their happiest and most fulfilling moments as when they saw individuals recover from illness or whole communities change their health behavior or outcomes, as one health extension worker from a lower-performing rural woreda reflected:

I am happy for contributing toward reducing mothers and children death; we haven’t had mothers dying here with us, but we used to lose children. After 2005 we have seen special changes, and home delivery rate is getting to zero. Delivering a child at home is considered almost a taboo these days…We used call on households for vaccination, but today there is no need to call for vaccination as [people] come themselves on the 27^th day. This is what makes me happy, a change of attitude. (Health extension worker; lower performing, rural; P83, W6)

Individuals in higher-performing and lower-performing woredas also shared a common view of what demotivated them. Participants described perceptions of limited career growth opportunities and inadequate financial compensation. In addition, staff reflected on the demotivation caused by poor supervision, including both inattentive supervisors and lack of clear role definition by supervisors. From a lower-performing urban woreda, one health extension worker said:

There is no one who follows up on our performance and gives us moral support and criticizes our weaknesses…We cannot be successful without follow-up and encouragement. You begin with courage and determination, but due to the lack of moral support you become discouraged. (Health extension worker; lower performing, urban; P28, W4)

From a higher-performing rural woreda, one health center staff member voiced frustration in not having clarity about his job responsibilities:

[HMIS focal persons] are expected to do the secretarial work, the archives work in addition to their assignment. Their major problem is that they don’t know what is expected from them. There has to be a job description. They are asking their bosses to tell them what to do and what is expected from them. One of them will come and say do this and the other will say another…the major problem in many places is lack of job description. (Health center staff; higher performing, rural; P7, W2)

Weak connections with hospitals and other components of primary health care: Participants from all levels and across both higher-performing and lower-performing primary health care units noted gaps in the linkages between hospitals and health centers or health posts. Health center staff, health extension workers, and community members reported vignettes of patients being discharged from the hospital back to the community without sharing information about needed follow up, as illustrated by this quotation from a health center director working in higher-performing rural primary health care unit:

There is no feedback from [the] hospital that says you have sent such patients and [we] have reached this result…We don’t know whether the patients are dead or alive. For example, there are poisoned patients, which were beyond our capacity, and we referred them. We hear from others that some of them died. Otherwise they don’t inform us through feedback. (Health center director; higher performing, rural; P32, W2)

Conversely, hospital-based staff complained that patients were often referred to the hospital without prior notification and at times when no beds were available. Some indicated that patients unnecessarily bypassed health centers and accessed the hospital directly despite their condition being treatable at the health center as described by a referral focal person from lower-performing rural woreda.

Referral linkages are mostly very poor…In relation to delivery, they send cases to which solution can be sought at the health centers, [and there are] shortcomings in the information about the patient that they are supposed to record and send to us. (Hospital referral focal person; lower performing, rural; P15, W5)

Although a minority perspective, one hospital medical director in an urban setting described effective linkages, including training and financial support from the hospital to the health center; these linking processes were implemented by an exemplar hospital, as described by the medical director in a higher-performing urban woreda:

Our hospital is a “LEAD” hospital, and we have monthly meeting with health center heads and delivery room workers. We discuss major challenges and how to tackle the challenges. They present what they have been doing in the past one month like how many they referred, how delivery service [was] conducted. We have a liaison officer who compiles all referrals from the health centers, and summary reports are given to the health centers. The mid-wives at health centers come here and get trained on …basic essential obstetric care and newborn care, and we have strong relationships. We give them supplies…We know what support they require to deliver better service. And we will do all possible to make that a reality. (Hospital medical director; higher performing, urban; P47, W7)

Health extension workers’ challenges in urban communities: Health extension workers and others interviewed suggested a mismatch between what the health extension workers are prepared to offer and what the urban-dwelling, higher-income community wants related to health care. Urban dwellers were described as wanting access to clinical care with a physician, not a health extension worker, even in cases when the health extension worker was a nurse. As stated by people interviewed in higher-performing urban woreda:

The [higher-income] group will create a challenge. They may claim to have their own doctor, and they don’t want to spend their time with the health extension workers. They may not respond when their door is knocked. (Woreda administrator; higher performing, urban; P50, W7)

Most [urban] people think that they know a lot, and when you tell them about the washing facility after [using the] toilet, most of them think that it is a rural thing to do…there are cases when people disappear, hide, or abandon their place whenever you attempt to approach them. (Health extension worker; higher performing, urban; P69, W1)

Another challenge in the urban settings was described as the diversity of people and their activities, and difficulty finding them at home, as illustrated by this quotation of a supervisor of health extension workers in a higher-performing urban setting.

The complex socio-cultural diversity and economy [is a challenge]. If you go to rural areas homogeneity is more observed in the form of culture and language, and it is relatively easier there. For example, there could be a religious holiday and you could get all villagers assembled. But here they [urban residents] work 24 hours and asking health extension workers to find them during weekends is very difficult. (Health extension worker supervisor; higher performing, urban; P49, W7)

Last, participants reported that more educated urban community members seemed to look down on health extension workers and not value their work, as described by a health extension worker from a lower-performing urban setting:

They consider themselves educated and they speak to you rudely when you attempt to advise them. They consider us nagging. They avoid us when we try to approach them. (Health extension worker; lower performing, urban; P39, W4)