Fetene Netsanet, Linnander Erika, Fekadu Binyam, Alemu Hibret, Omer Halima, Canavan Maureen, Smith Janna, Berman Peter, Bradley Elizabeth
Yale School of Public Health and Global Health Institute, New Haven, CT, United States of America.
JSI Research and Training Institute, Inc., Boston, MA, United States of America.
PLoS One. 2016 May 26;11(5):e0156438. doi: 10.1371/journal.pone.0156438. eCollection 2016.
Primary health care services are fundamental to improving health and health equity, particularly in the context of low and middle-income settings where resources are scarce. During the past decade, Ethiopia undertook an ambitious investment in primary health care known as the Ethiopian Health Extension Program that recorded impressive gains in several health outcomes. Despite this progress, substantial disparities in health outcomes persist across the country. The objective of this study was to understand how variation in the implementation of the primary health care efforts may explain differences in key health outcomes.
We conducted a qualitative study of higher-performing and lower-performing woredas using site visits and in-depth interviews undertaken in 7 woredas. We classified woredas as higher-performing or lower-performing based on data on 5 indicators. We conducted a total of 94 open-ended interviews; 12-15 from each woreda. The data were analyzed using the constant comparative method of qualitative data analysis. Substantial contrasts were apparent between higher-performing and lower-performing woredas in 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 higher-level regulatory and financing bodies at the zonal and regional levels. We found similarities in what was reported to motivate or demotivate health extension workers and other staff. Additionally, higher-performing and lower-performing woredas shared concerns about hospitals being isolated from health centers and health posts. Participants from both woredas also highlighted a mismatch between the urban health extension program design and the urban-dwelling communities' expectations for primary health care.
Data-informed problem solving, respectful and supportive relationships with the community, and strong support from zonal and regional health bureaus contributed to woreda performance, suggesting avenues for achieving higher performance in primary health care.
初级卫生保健服务对于改善健康状况和健康公平性至关重要，尤其是在资源稀缺的低收入和中等收入环境中。在过去十年中，埃塞俄比亚对初级卫生保健进行了一项雄心勃勃的投资，即埃塞俄比亚卫生推广计划，该计划在多项健康成果方面取得了令人瞩目的进展。尽管取得了这一进展，但全国范围内健康成果仍存在巨大差异。本研究的目的是了解初级卫生保健工作实施过程中的差异如何解释关键健康成果的差异。
我们通过实地考察和对7个区进行深入访谈，对表现较好和表现较差的区进行了定性研究。我们根据5项指标的数据将区分为表现较好或较差。我们共进行了94次开放式访谈；每个区12 - 15次。使用定性数据分析的持续比较法对数据进行了分析。在利用数据解决问题和改进绩效、卫生推广工作者、社区成员和卫生中心工作人员之间的协作和尊重关系，以及区卫生办公室与区域和州级更高层次的监管和融资机构之间的协调方面，表现较好和表现较差的区之间存在明显差异。我们发现，在据报告激励或打消卫生推广工作者及其他工作人员积极性的因素方面存在相似之处。此外，表现较好和表现较差的区都对医院与卫生中心和卫生站隔离表示担忧。来自这两类区的参与者还强调了城市卫生推广计划设计与城市社区对初级卫生保健的期望之间的不匹配。
基于数据的问题解决、与社区建立尊重和支持性的关系，以及区域和州级卫生局的大力支持有助于区的绩效提升，这为在初级卫生保健方面实现更高绩效指明了方向。
