Strong health systems are highly dependent on good performance of health information systems at primary health care entities (1). Data quality is characterized as timely, credible, accurate and complete data that can be effectively used to track program performance, and thus positively impact strategic planning and decision-making processes (4, 5). Low- and middle-income counties have been working to strengthen their routine health information system in terms of building sustainable use of quality data for evidence-based practices and patient care at primary health care units to ensure universal health care (1). Ethiopia has made significant investments on improving the performance of HIS at all levels of the health system (2). Moreover, the performance of HIS contributes towards the country’s HIS capacity, data quality and information use (2, 3). Despite the several efforts that have been exerted to strengthen the performance of HIS, there are persisting gaps in governing the HIS to produce quality data and information use for decision making at all levels of the health system. Among the gaps are the absence of a HIS governance framework, weak enforcement on standards, lack of standards for some digitalized health systems (e.g. EMR), absence of interoperable systems, and poor data demand and information use culture.
In addition, Ethiopia grapples with poor quality data production and limited information use at primary health care entities due to poor documentation, incomplete and untimely reporting, and low HIS capacity at the lower levels of the health system (6). This can lead to limited information use and wrong decision making in health service delivery and health programs (6). Ethiopia has introduced the connected woreda strategy as an integral part of its national HIS strategy termed the information revolution agenda (2) which is one element of the country’s transformation agenda stated in its five-year Health Sector Transformation Plan (HSTP) (2, 6).
The connected woreda strategy (CWS) is defined as a tool that strengthens the performance of the health information system (HIS) at primary health care entities (7). The CWS is an indigenous, district level HIS performance monitoring tool that improves HIS capacity, data quality and information use culture at the point of data production (2, 6, 9).
The CWS applies assessment tools that check the status of primary health care units on a quarterly basis through continuous mentorship and coaching activities (7). The assessment tool has 18 major and 36 composite criteria categorized as: HIS capacity (30%), data quality (30%), and information use (40%). The connected woreda strategy is being implemented all over the country at the primary health care level as part of Ethiopia’s transformation agenda (7).
The CWS has begins with an accreditation process where woredas/districts are evaluated and scored against a common set of criteria related to HIS resource, data quality, and administrative processes. Woredas/districts that meet the highest standards, ( > = 90% of common set of criteria), are recognized as ‘model woredas’, woredas/districts that meet medium standards, (between 65–90% score of common set criteria) are recognized as ‘candidate woredas’ and woredas/districts that meet lowest standards (< 65 of common set of criteria) are recognized as ‘emerging woredas’. Woredas that enable online data access and transmission in addition to being ‘model woredas’ are recognized as ‘connected woredas’ (6). The contribution of the CWS towards the improved performance of HIS has yet to be documented.
The USAID Transform: Primary Health Care Activity has been providing technical and financial support to the government’s strategic initiatives in Amhara, Oromia, SNNPR and Tigray regions. A total of 400 districts, 1,856 health centers and 9,291 health posts, and 122 primary hospitals are covered by the Activity through the provision of phased and adaptive technical assistance. The Activity has integrated the CWS practices as part of the key components of its interventions to improve the performance of HIS and create a culture of information use for evidence-based practices at primary health care entities. This study will assess the connected woreda strategy in improving the culture of information use through pre and post analysis of primary health care entities in Ethiopia.
I. The connected woreda strategy (CWS) is a tool to create model/high performer woredas/districts in use of data for planning, budgeting and evidence-based practice to improve service delivery and patient care. The initiative operationalizes data-use innovations through instituting a tiered pathway for woredas/districts to achieve the highest standards in data quality and use. The pathway begins with an accreditation process where woredas/districts are evaluated and scored against a common set of criteria related to HIS resource, data quality, and administrative processes. Woredas/districts that meet the highest standards, ( > = 90% of common set of criteria), are recognized as ‘model woredas’, woredas/districts that meet medium standards, (between 65–90% score of common set criteria) are recognized as ‘candidate woredas’ and woredas/districts that meet lowest standards (< 65 of common set of criteria) are recognized as ‘emerging woredas’. Woredas that enable online data access and transmission in addition to being ‘model woredas’ are recognized as ‘connected woredas’. (7). See the Fig. 1 below on the framework of connected woreda strategy pathway.
II. Health information technicians are data managers responsible for the implementation of the routine health information system and that mainly perform activities such as data collection, data cleaning, data analysis, data production as well as data dissemination and use at the district level.
III. Health management information system (RHMIS): In Ethiopia, the HMIS is managed by the Federal Ministry of Health and is a primary source of information for the continuous monitoring of health services in the whole In response to socio-economic changes, disease patterns and the introduction of international strategies, the current HMIS incorporates standardized new initiatives.
USAID Transform: Primary Health Care is working on the implementation the (CWS) to improve the performance of HIS at primary health care levels. CWS applies tools that improve HIS system and capacity, data quality and administrative data use which are major factors affecting the performance of HIS at the primary health care level. As part of this effort, the Activity’s major intervention areas were categorized as: 1. training, 2. mentorship and coaching, and 3. best practice sharing. Each of these categories are described below.
1. Training: USIAD Transform: Primary Health Care developed a five-day training material on use of data for decision making (UDDM) for primary health care entities. The content of the training includes CWS as part of HIS reform agenda, health management information system (HMIS), performing lot quality assurance sampling (LQAS), district health information system 2 (DHIS2), electronic community health information system (eCHIS), etc. (Additional file 2). The Activity, in collaboration with Regional Health Bureaus (RHBs), provided training of trainers (TOT) on UDDM for 106 regional and zonal health information technicians within Amhara, Oromia, SNNP and Tigray regions. UDDM TOT trained professionals were then mentors for health information technicians (HIT) at district and primary health care entities. A total of 677 HIT professionals were trained on UDDM from district offices and primary health care units within Amhara, Oromia, SNNPR and Tigray regions to improve performances of HIS at the point of data generation. In addition, gap filling HIS inputs such as 667 push pin boards for data visualization were procured and distributed to primary health care entities. Moreover, the DHIS2 application was installed for HIT professionals for data collection, analysis, data visualization and reporting purposes. Program monitoring dashboards were created on the DHIS2 application by UDDM trained HIT professionals to improve data use and evidence-based practices at the primary health care level.
2. Mentorship and coaching: USIAD Transform: Primary Health Care provided continuous mentorship and coaching for HIT professionals at the primary health care level. An average of four coaching sessions were conducted using the CWS such as HIS capacity e.g. availability of adequate human resource, HIS budget, system structure and supportive supervisions; data quality e.g. timely completion and reporting, high quality data (highly detailed), and proper use; administrative data use e.g. a functioning performance monitoring team (PMT), data analysis and dissemination (coverage, equity, quality indictors) (7). See the Fig. 2 below on connected woreda strategy (CWS) assessment criteria.
In addition, on average, four mentorship and coaching sessions were delivered, and tailor-based support was provided for each district and primary health care unit on a quarterly basis. During each mentorship and coaching session, priority problems/challenges were identified using CWS assessment criteria, solutions were identified, and action plans were prepared and regularly reviewed. Average scores for each mentorship and coaching session were registered at a baseline score of 60% ‘emerging’; a 1st session coaching score of 65% ‘candidate’; a 2nd session coaching score of 68% ‘candidate’; a 3rd session coaching score of 72%‘candidate’, and a 4th session coaching score of 78% ‘candidate’. Moreover, USAID Transform: Primary Health Care developed and implemented an Excel based dashboard and created a data use forum through a phone application channel, (Telegram), to facilitate mentorship and coaching on CWS at the district level. Furthermore, the created forum contributed significantly to experience sharing of best practices on HIS performance among HITs at district and primary health care levels. Sharing of best practices: USAID Transform: Primary Health Care has been working to strengthen learning collaborative forums between ‘emerging’ and ‘model’ districts and primary health care entities through the Ethiopian primary health alliance for quality (EPAQ) initiative. EPAQ is an Ethiopian health reform initiative used as a learning collaborative forum and is designed facilitate experience sharing, learning forums and collaboration to improve service delivery at primary health care entities. The ‘model’ districts were the facilitators of the EPAQ forum, and the remaining four districts were members. Both lead and member districts identified thematic areas for collaboration and signed an agreement. This created linkages between high performing ‘model’ and low performing ‘emerging’ districts. As a result, various success stories on HIS capacity, data quality, and information use were compiled from ‘model’ districts were shared with ‘emerging’ ones within Amhara, Oromia, SNNPR, and Tigray regions. A total of eight EPAQ forums were organized at the district level in collaboration with partners working at the primary health care level (20, 21).