Twinning Partnership Helps to Accelerate the Performance of District Health Systems Towards Achieving Universal Health Coverage

Background The twinning partnership is a formal and substantive collaboration between two districts to improve their performance in providing primary healthcare services. The ‘win-win’ twinning partnership pairs relatively high and low performing districts. The purpose of this formative evaluation is to use the empirically derived systems model as an analytical framework to systematically document the inputs, throughputs and outputs of the twinning partnership strategy. Methods This evaluation employed a case study research design and was conducted from October 2018 to September 2019, in Amhara, Oromia, Southern, Nations, Nationalities and Peoples’ (SNNP) and Tigray Regions. Qualitative data was collected using interviewer-guided semi-structured interview tools. The data were transcribed verbatim, translated into English and analyzed through the theoretical framework called Bergen Model of Collaborative Functioning (BMCF). Quantitative data were extracted from Routine Health Management Information System. Results were presented using average, percentages and graphs. Result The result of this case study revealed that scanning the mission of the twinning partnership and focusing on a shared vision coupled with mobilizing internal and external resources were the fundamental input element for successful twinning partnership at the district level. In addition, the context of pursuing Universal Health Coverage (UHC) through achieving transformed districts can be enhanced through deploying skilled and knowledgeable leadership, defining clear roles and responsibilities for all stakeholders, forming agreed detailed action plans and effective communication that leads to additive results and synergy. The twinning partnership implementing districts benefit from the formal relationship and accelerate their performances towards meeting criteria of transformed districts in Ethiopia. At the baseline measurement stage, only two out of eight districts achieved a medium performance status; at mid-term, two districts achieved high performance status and during the end-line results out of eight twinning targeted districts, three districts fulfilled the transformation criteria, three districts were categorized as medium performers and the remaining two districts fell into the low performing districts category. Conclusions The implemented partnership helped

performance in achieving the district transformation criteria. Therefore, scaling up the implementation of the twinning partnership strategy is recommended.

Background
Ethiopia has successfully achieved the targets set in the Millennium Development Goals (MDGs), which have been implemented for the past two decades -from 1995 to 2015. During this period, the government of Ethiopia has put in place a national health policy and several health reforms that have improved the overall performance of the health system. Government commitment, the support of development partners and community-level engagement, have contributed to the improved and remarkable health outcomes (1,2). Some of the gains realized by 2016 include a reduction in the Maternal Mortality Ratio (MMR) from 1400 to 351/100000 live births, and a decline in the under-five mortality rate by 67%, to 68 deaths per 1000 births (3). The current Health Sector Transformation Plan (HSTP) strategizes to maintain the country's success towards realizing Universal Health Coverage (UHC) by implementing four transformation agendas which consist of: (1) quality and equity of health services, (2) Caring, Respectful and Compassionate (CRC) health workforce, (3) information revolution, and (4) woreda transformation (3). This requires closing the gap between high and lowperforming district (woreda) health offices and adopting and implementing innovative service delivery and management solutions (3) as one of the major obstacles to transformation is the wide variance of know-how, skills, competencies and performances within woreda health systems and/or among woredas within zone administrations and regions.

The Case
The USAID Transform: Primary Health Care project targets 360 districts in four regional states of Ethiopia. Within these project targeted regions there are: 114 primary hospitals; 1,837 health centers; and 9,538 health posts (4). Using the public sector's routine Health Management Information System (HMIS) reports, 12 maternal and child health-related service indicators were selected and collated. performers and the lower one-third districts are categorized as low performing (5). Based on the above described indicators, the project began its support with the baseline composite score status of 47 (13%), 115 (32%) and 198 (55%) of targeted districts which were high, medium and low performing, respectively. By 2021, the project is committed to achieve high or medium performance status in 310 (86.1%) districts through institutionalizing innovative performance management and improvement tools (4). Furthermore, the Ministry of Health has defined a set of criteria which include District (woreda) Management Standards (10.0%); Model Village (30.0%); High Performing Primary Health Care Units (30%); and Financial Risk Protection through high membership and renewal coverage of the Community-based Health Insurance scheme (30%). Using the overall scores, districts which achieved greater or equal to 85.0% were considered as high performers; districts which achieved between 60-84.9% were medium performers and districts which achieved less than 60% were low performer districts. By the end of September 2018, out of 1081 districts, no districts achieved over 85%.
In 2017, the Ethiopian Federal Ministry of Health (FMOH), and Regional Health Bureaus (RHBs) in collaboration with the project piloted the 'Twinning Partnership Strategy' to accelerate district health system performance as a result of synergy, that is, district transformation as an outcome through working with others, which leads towards UHC (6)(7)(8)(9)(10)(11).
According to Cadée et al. 2016, twinning is a cross-cultural, reciprocal process where two groups of people work together to achieve joint goals (12). Similarly, twinning is defined as a formal and substantive collaboration between two organizations (6, 10). Formal means that there is a verbal or written agreement between the two organizations. Substantive means that the interaction is significant, and that it lasts for a specific period i.e., it is not a one-time interaction. Collaboration means that the two organizations work together on a specific project or to exchange information or skills (7).
The main purpose of this formative evaluation is using an empirically derived systems model as an analytical framework to systematically document the inputs, throughputs and outputs parameters of BMCF theoretical framework (Fig. 1), in Ethiopia, where twinning partnership strategy implemented between districts targeting UHC through achieving district transformation.

Methods
A case study design, (Yin 2014) was employed (22). The study focused on eight districts that had The study's target population were managers, healthcare workers of the district health offices, and primary healthcare units which are within the study areas. In addition, records and documents of the twinning partnership strategy activities in all eight districts were reviewed as a main source population for data extraction.
This study used purposive sampling methods. Firstly, four regional states and eight districts were selected based on their experience of implementing the twinning partnership strategy. Secondly, thirty-nine In-depth Key Informants (IKI), of which 6 were females were enrolled until data saturation was reached, as a result of redundancy of information.
Data collection guides were developed based on research objectives and questions. In addition, data extraction forms were developed based on the principles of the twinning partnership strategy implementation guidelines and district transformation criteria. The tools were piloted in two selected districts. Before developing the final data collection tools, the necessary amendments were made based on pilot test results. The data were collected using in-depth individual interviews with healthcare professionals of primary health care entities who were actively engaged in the implementation of the twinning partnership strategy. A nationally developed and endorsed selfassessment and validation tools were adapted for this study to measure the performance status of Data on performance of district health system were abstracted from routine health management information system reports and reports of external validation teams.
The qualitative data were transcribed verbatim and translated from Amharic into English. To interpret the data, the investigators read and re-read the transcripts several times for better understanding.
Emerging ideas were written, and codes were created with grouping and regrouping of codes to topics with corresponding similarities (23). In addition, the Bergen Model of Collaborative Functioning (BMCF) theoretical framework, was used as a basis for interpreting the findings (19)(20)(21). Base line, mid-term and end line data were extracted, checked for its consistency, completeness, reliability and analyzed to track observed changes following the implementation of twinning partnership as a new initiatives. Quantitative data were analyzed using frequencies, proportions and graphs.

Ethical Considerations
This study protocol was reviewed at the JSI Research & Training Institute, Inc. Institutional Review Board (IRB). The IRB has determined that this activity is exempted from human subjects' oversight (IRB #19-31E). Support letters were sought and obtained from the Amhara, SNNP, Oromia and Tigray regional state health bureaus. Permission to conduct the study was sought from the selected health facilities and informed written consent was obtained from all study participants. All study subjects, whose age is greater or equal to 18 years, were informed that they have the right to discontinue or refuse to participate in the study at any time. The investigator has maintained the anonymity, privacy and confidentiality of the participants throughout the research process.

Mission
In this study 'mission' means the main reason stated for the existence of the twinning partnership. A common understanding of the mission and the health system's strategic priorities enhance access to quality primary healthcare services in an equitable manner. Such systematic interventions help the Ethiopian health sector to create a resilient district health system which is responsive to the needs and demands of every individual at all places. These collective and widespread comprehensions help members of the twinning facilities to develop a shared vision that inspire partner districts and their staff, share resources, develop a culture of serving communities outside their district boundaries and grow and become stronger together while maintaining a sense of competitiveness among members.
This indicates that the implementation of health sector reforms enhances the governance, capacity, quality, equity of access to primary health care services. The following verbatims describe the opinions of health workers on their understanding of the mission and shared vision of the twinning partnership strategy. Outputs Three major categories were discussed under outputs. First, the summary of additive results, then synergy and antagonistic results will be presented below.

Additive results
Additive results implied the implementation of health sector priority separately without considering the effect of implementing the twinning partnership. The majority twinning partnership targeted districts reported their engagement through orientation of health sector reforms, facilitated selfassessment against standards and provide routine health services. A district health office head said: " …the health office organizes and facilitates orientation of health sector reforms." (011, District Health Office Head, BSc nurse, Tigray Region).
Another health worker had this to say about the routine activities in their office implemented regularly: "Every quarter, the performance management team assesses performance against the standards." (001, Health Center Director, Health Officer, Oromia Region)

Synergy
The implementation of the twinning partnership strategy helps partner districts achieve results which would not be achieved through the sole the efforts of either individuals or districts alone.
A health worker describes the additive results of the established twinning partnership saying; "… though we had relatively higher performances than our partner low performer district within the partnership, we heard about experiences of implementing challenging interventions from our twin woreda, [name]. We also adopted the best practices and collected the list of items essential for maternal waiting homes and audio-visual job aids." (034, Health Center Director, BSc Nurse, Amhara Region).
All twinning partnership targeted districts were rated on three occasions; namely, baseline, mid-term and end-line stages. Figure 2. below depicts that six and two districts were categorized as low and medium performers at baseline measurement, respectively. These scores were improved at mid-term as two, two and four districts categories as high, medium and low performing districts, respectively.
The end-line results revealed that out of eight districts, three fulfilled district the transformation criteria, three were categorized as medium performers and the remaining two districts despite improving the scores, fell in the low performing districts category. Both low and medium performing districts benefited from the implemented twinning partnership strategy which reinforces the argument that these achievements would have come about without the twinning partnership exercises.

Antagonistic results
Despite the additive results and synergy observed among partnering districts, there were some observed antagonistic results. During the experience sharing events as well as while conducting integrated supportive supervisions, some staff did not know the reason for the established partnership and the investment appeared to them as a waste of resources.
"While we were motivated to share our knowledge and skills to partner district staff, they perceived us as having travelled over 90 kilometers to get financial rewards form our meals and accommodation expense payouts." (032, District Health Office Vice Head, BSc Nurse, Amhara Region) Some of health the workers pointed out that lack of transparency in decision making and lack inclusion of all departments in the established twinning partnership had a negative impact on achievements. Furthermore, they describe the demotivating effects of lack of good governance on collaborative efforts.

Discussion
The twinning partnership strategy implemented in four regional states of Ethiopia clearly demonstrates the win-win collaboration functioning between districts that fall under medium and low performance categories. The main purpose of this formative evaluation report is to demonstrate the effects of the twinning partnership on the performance of district transformation which is the main strategy to achieving UHC in Ethiopia. In addition, the research unveiled the positive and negative factors which enhance or deter the outputs of the twinning partnership (19).
Scanning the mission of the twinning partnership and primary health care entities and focusing on the health sector's top priorities in the context of district transformation was helpful to members of the twinning partnership in developing their shared vision. The shared vision helped leaders and managers to persist in achieving results beyond their districts. It also helped the district health system to identify stakeholders and define structures, roles and responsibilities. A common understanding on the purpose of the twinning partnership assisted the district health system's staff to improve their negotiation skills on convincing decision-making bodies to fulfill minimum human, material and other resources. (24,25) The Ethiopian health sector's strategic plan strives to achieve UHC through transforming households, villages and primary health care units (3). The most important element of district transformation is having capable health sector leaders. Visionary leaders who have the knowledge and skills of scanning, focusing, inspiring, aligning and organizing resources were identified as the essential element of implementing collaborative functioning. The training offered to staff of districts engaged in twinning partnership to understand the component of strategic problem-solving tools which includes mission and shared vison, desired measurable results, obstacles, challenge statement and priority solutions. The training also assists partners to develop a one-year twinning partnership detailed activity plan.
The piloting of the twinning partnership strategy has revealed the additive results, synergy and antagonistic results on both partner districts. The results showed that partner districts shared tools, guidelines and were able to organize regular integrated supportive supervision and review meetings.
Furthermore, through implementing components of collaboration functioning, both medium performing and low performing districts closed-in on achieving universal health coverage, through addressing the root causes for all social inequalities in the availability, access, quality and burden of out of pocket payments.
The case study revealed that the twining partnership strategy, which was adopted from WHO's twinning partnership for improvement, helps the performance of the district health system to accelerate transformation towards UHC. This finding was consistent with Bitton et al (2017)

Conclusions
Based on the results of the formative evaluation, the twinning partnership strategy piloted in eight districts of Ethiopia helped partner districts to accelerate their performance towards fulfilling district transformation criteria and assisted them towards achieving UHC (9). The twinning partnership strategy also helped district health systems to standardize services and build their leadership's capacity which were fundamentally important in achieving results. USAID Transform: Primary Health Care project, the Ministry of Health, Regional Health Bureaus and other development partners shall support the scale up of this innovative performance improvement tool -twinning partnership -so that