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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 p 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 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.

Background Leadership, management, and governance (LMG) interventions play a significant role in improving management systems, enhancing work climate, and creating responsive health systems. The Federal Ministry of Health with the support of USAID Transform: Primary Health Care project, cascaded its basic LMG trainings and interventions to primary health care staff. The purpose of this evaluation was to measure the changes observed on performance improvement at primary health care entities after implementing the interventions for one year. The results of this research will help policy makers, program managers, and implementers to make informed decisions in the area of performance improvement. Methods The study used a quasi-experimental pre-post survey design to assess the changes observed as a result of LMG in performance management at primary health care entities. It was conducted from August 28, 2017 to September 30, 2018 in Amhara, Oromia, Tigray, and Southern Nations, Nationalities and Peoples Regions. The data was collected through document review and interviewer and self-administered questionnaires across 136 health facilities, in which there are 293 health workers who attended the LMG training; and 333 health workers who did not attend the training. In addition, training records were reviewed to capture change in knowledge and skill through pre-post training and, baseline and end-line performance improvement project achievements, respectively. The data were analyzed using SSPS IBM V 20. Results The response rates were 100% for staff who attended the training; and 87% for staff who did not attend the training. Of those who attended the training, 235 (80.9%) and 252 (86%) trainees scored above 70% on post-test, and 80% or more achieved the desired measurable results of their performance improvement projects. Using the above-mentioned criteria, composite scores were compiled from post-test and performance improvement project results. The result showed that 70% (205/293) of basic LMG trainees completed the course. As a result of the LMG trainings, management systems, work climate, and responsiveness of the health system to challenges significantly improved (p

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 twinning partnership helped 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.

Additional file 6. 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.

High quality care-at a minimum-is a combination of the availability of tangible resources as well as a capable and motivated health workforce. Researchers have suggested that supportive supervision can increase both the performance and motivation of health workers and the quality of care. This study is aimed at assessing the required number of visits and time between visits to bring about improvements in health service delivery. The study employed a primary health care performance improvement conceptual framework which depicts building blocks for improved health service delivery using longitudinal program outcome monitoring data collected from July 2017 to December 2019. The analysis presented in this study is based on 3,080 visits made to 1,479 health centers in the USAID Transform: Primary Health Care project's intervention districts. To assess the effects of the visits on the repeated measure of the outcome variable (Service-Delivery), multilevel linear mixed model (LMM) with maximum likelihood (ML) estimation was employed. The results showed that there was a significant dose-response relationship that consistent and significant improvement on Service-Delivery indicator was observed from first (β = -26.07, t = -7.43, p < 0.001) to second (β = -21.17, t = -6.00, p < 0.01), third (β = -15.20, t = -4.49, p < 0.02), fourth (β = -12.35, t = -3.58, p < 0.04) and fifth (β = -11.18, t = -2.86, p < 0.03) visits. The incremental effect of the visits was not significant from fifth visit to the sixth suggesting five visits are the optimal number of visits to improve service delivery at the health center level. The time interval between visits also suggested visits made between 6 to 9 months (β = -2.86, t = -2.56, p < 0.01) showed more significant contributions. Therefore, we can conclude that five visits each separated by 6 to 9 months elicits a significant service delivery improvement at health centers.