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Research article
Accelerating the performance of district health systems towards achieving UHC via twinning partnerships
Mesele Damte Argaw
JSI Research and Training Institute Inc
Corresponding Author
ORCiD: https://orcid.org/0000-0002-9558-6619
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Health Services Research.
Background: A 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 are categorized under 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 explanatory sequential mixed method study design was conducted from October 2018 to September 2019, in Amhara, Oromia, Southern, Nations, Nationalities and Peoples’ (SNNP) and Tigray regions. The quantitative research approach used an observational design which consists of three measurements: at baseline (October 2018), midterm (March 2019) and end-line (September 2019), and the qualitative approach employed a case study. Qualitative data was collected using interviewer-guided semi-structured interview tools. The data were transcribed verbatim, translated from Amharic and Afan Oromo into English and analyzed through a theoretical framework named the Bergen Model of Collaborative Functioning (BMCF). Quantitative data were extracted from routine health management information system. The results are presented as averages, percentages and graphs. To claim statistical significance, non-parametric tests: Friedman test at (p<0.05) and Wilcoxon signed ranks test (p<0.017) were analyzed.
Results: The District Health System Performance (DHSP) was determined using data collected from eight districts. At baseline, the mean DHSP score was 50.97, at midterm, it was 60.3 and at end-line, it was 72.07. There was a strong degree and statistically significant relationship between baseline, midterm and end-line DHSP scores (r>0.978**), using the Friedman test χ2(2) = 16.000, p = 0.001. Post hoc analysis using Wilcoxon signed-rank test was conducted with a Bonferroni correction and the results elicit higher DHSP values from baseline to midterm and from midterm to end-line with significance level set at p<0.017. The qualitative results of the 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 elements for successful twinning partnerships 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 the criteria of transformed districts in Ethiopia.
Conclusions: Twinning partnerships help to accelerate the health system’s performance in achieving the district transformation criteria. Therefore, scaling up the implementation of the twinning partnership strategy is recommended.
Keywords
Twinning Partnership, Universal Health Coverage, Transformation, Ethiopia
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This is a list of supplementary files associated with this preprint. Click to download.
- 1DistrictManagementStandardschecklist.xlsx
Additional file 1: District (woreda) management standards self-assessment & validation checklist. The District management standards is a set of 26 management minimum standards with 81 verification criteria. The self-assessment and validation checklist is used to identify strengths and gaps, useful for performance improvements. The tool is used by both partner districts for performance management on a monthly basis. In addition, the zone health department organizes validation measurements on a semi-annual basis. The overall scoring is rated from 0.0% to 100.0%.
- 2Modelvillagechecklist.xlsx
Additional file 2: Model village checklist The overall scores on model villages will be converted out of 30.0%, which is assessed through model households, model schools improved latrine coverage, and skilled delivery coverage. The results will also contribute to district transformation criteria scores.
- 3CommunityBasedHealthInsurancechecklist.xlsx
Community-Based Health Insurance checklist. Community-Based Health Insurance household membership is calculated on an annual basis. Hence, the tool helps to organize memberships into new enrollments and renewals. Net active household membership scoring is rated from 0.0% to 100.0%. The results will be converted out of 30.0% and contributes to district transformation criteria.
- 4KeyPerfromanceIndicators.xlsx
Key Performance Indicators checklist The Key Performance Indicators are 18 in number. Each indicator is scored out of 100.0% but based on their importance, the Ministry set weights for each one. The overall score will be converted to 35.0% and will contribute scores to categorizing primary health care units.. The results will also contribute to high performing PHCU scores.
- 5EHCRIGsassessmentchecklist.xlsx
Ethiopian Health Center Reform Implementation Guidelines (EHCRIGs) checklist. EHCRIGs are a set of 81 standards with 209 composite validation criteria. EHCRIGs assessment checklist is developed to perform self-assessment on a quarterly basis after which the district health office facilitates validation measurements on a semiannual basis. The performance management team and quality improvement committee use the information for performance and quality improvement initiatives. The overall scoring is rated out from 0.0% to 100.0% and translated into 35.0%.
- Additionalfile6.docx
In-depth interview guide. The in-depth interview guide was developed after reviewing relevant literatures (17, 24). The guide has three sections, an ice breaker, main question and probing questions.
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CURRENT STATUS: Published
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On 21 Sep, 2020
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Submission checks complete
On 17 Sep, 2020
Editorial decision: Accept
On 16 Sep, 2020
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Editorial decision: Minor revision
On 09 Sep, 2020
Review #2 received
Received 06 Sep, 2020
Review #1 received
Received 25 Aug, 2020
Reviewer #2 agreed
On 17 Aug, 2020
Editor assigned
On 17 Aug, 2020
Reviewers invited
Invitations sent on 17 Aug, 2020
Reviewer #1 agreed
On 17 Aug, 2020
Submission checks complete
On 16 Aug, 2020
Editor invited
On 16 Aug, 2020
No comments provided
Editorial decision: Major revision
On 17 Jul, 2020
Review #2 received
Received 01 May, 2020
Review #1 received
Received 01 May, 2020
Reviewer #2 agreed
On 13 Apr, 2020
Reviewer #1 agreed
On 08 Apr, 2020
Editor assigned
On 30 Mar, 2020
Reviewers invited
Invitations sent on 30 Mar, 2020
Submission checks complete
On 29 Mar, 2020
Editor invited
On 29 Mar, 2020
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This preprint is under consideration at BMC Health Services Research. A preprint is a preliminary version of a manuscript that has not completed peer review at a journal. Research Square does not conduct peer review prior to posting preprints. The posting of a preprint on this server should not be interpreted as an endorsement of its validity or suitability for dissemination as established information or for guiding clinical practice.
Learn more about In Review
Research article
Accelerating the performance of district health systems towards achieving UHC via twinning partnerships
Mesele Damte Argaw
JSI Research and Training Institute Inc
Corresponding Author
ORCiD: https://orcid.org/0000-0002-9558-6619
Badges
Prescreen
This manuscript passed our Prescreen assessment
Complete author information
Appropriate declaration statements
Potential risks to human health
Prescreen
Peer Review Timeline
CURRENT STATUS: Published
Version 3
Posted 17 Sep, 2020
Published
On 21 Sep, 2020
No community comments so far
Submission checks complete
On 17 Sep, 2020
Editorial decision: Accept
On 16 Sep, 2020
No comments provided
Editorial decision: Minor revision
On 09 Sep, 2020
Review #2 received
Received 06 Sep, 2020
Review #1 received
Received 25 Aug, 2020
Reviewer #2 agreed
On 17 Aug, 2020
Editor assigned
On 17 Aug, 2020
Reviewers invited
Invitations sent on 17 Aug, 2020
Reviewer #1 agreed
On 17 Aug, 2020
Submission checks complete
On 16 Aug, 2020
Editor invited
On 16 Aug, 2020
No comments provided
Editorial decision: Major revision
On 17 Jul, 2020
Review #2 received
Received 01 May, 2020
Review #1 received
Received 01 May, 2020
Reviewer #2 agreed
On 13 Apr, 2020
Reviewer #1 agreed
On 08 Apr, 2020
Editor assigned
On 30 Mar, 2020
Reviewers invited
Invitations sent on 30 Mar, 2020
Submission checks complete
On 29 Mar, 2020
Editor invited
On 29 Mar, 2020
First submitted
On 11 Mar, 2020
Metrics
Comments: 0
PDF Downloads: ...
HTML Views: ...
License:
This work is licensed under a CC BY 4.0 License. Read Full License
View the published version at BMC Health Services Research.
Background: A 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 are categorized under 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 explanatory sequential mixed method study design was conducted from October 2018 to September 2019, in Amhara, Oromia, Southern, Nations, Nationalities and Peoples’ (SNNP) and Tigray regions. The quantitative research approach used an observational design which consists of three measurements: at baseline (October 2018), midterm (March 2019) and end-line (September 2019), and the qualitative approach employed a case study. Qualitative data was collected using interviewer-guided semi-structured interview tools. The data were transcribed verbatim, translated from Amharic and Afan Oromo into English and analyzed through a theoretical framework named the Bergen Model of Collaborative Functioning (BMCF). Quantitative data were extracted from routine health management information system. The results are presented as averages, percentages and graphs. To claim statistical significance, non-parametric tests: Friedman test at (p<0.05) and Wilcoxon signed ranks test (p<0.017) were analyzed.
Results: The District Health System Performance (DHSP) was determined using data collected from eight districts. At baseline, the mean DHSP score was 50.97, at midterm, it was 60.3 and at end-line, it was 72.07. There was a strong degree and statistically significant relationship between baseline, midterm and end-line DHSP scores (r>0.978**), using the Friedman test χ2(2) = 16.000, p = 0.001. Post hoc analysis using Wilcoxon signed-rank test was conducted with a Bonferroni correction and the results elicit higher DHSP values from baseline to midterm and from midterm to end-line with significance level set at p<0.017. The qualitative results of the 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 elements for successful twinning partnerships 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 the criteria of transformed districts in Ethiopia.
Conclusions: Twinning partnerships help to accelerate the health system’s performance in achieving the district transformation criteria. Therefore, scaling up the implementation of the twinning partnership strategy is recommended.
Figure 1
Figure 2
Figure 3