Capacity and performance of primary health care in Ethiopia: a novel mixed methods measurement in low-income country.

Background: Universal access to essential health services is a global commitment; however, it remains a major challenge in low-income countries. Primary health care (PHC) is widely recognized as the most effective platform for delivering basic health interventions and essential public health functions. Assessing the capacity and performance of PHC provides critical information on the state of the PHC system and supports evidence-based decision-making to inform the design of targeted interventions.

Methods: The capacity and performance of the Ethiopian PHC system was assessed using a customized version of World Health organization's PHC Measurement Framework and Indicators (PHCMFI). PHC capacity was assessed across the domains of governance, financing, and input. PHC performance was assessed across domains of service availability and readiness, service quality, utilization, and coverage. Data were primarily obtained from secondary databases, supplemented by primary data collected through sixty-five key informant interviews from all regions of Ethiopia. A review of grey literature and national surveys was also conducted. Indicators for each domain were selected from the PHCMFI, and an unweighted average score was computed for each domain.

Results: PHC oriented policies and strategies exist at national and regional levels but with limited implementation capacity. PHC accounted for 78% of the total health expenditure, the per capita PHC expenditure was 28.3 USD and 40% of the source was from out-of-pocket. The average infrastructure score was 55%, essential medicines and basic laboratory diagnostic tests were available in 39% and 48% of facilities, respectively. The health workforce density for core health professional categories was 1.23 per 1,000 population and the average health-information system score was 38%. The average service availability score was 64%. Only 22% of health facilities had trained staff to provide antenatal care (ANC). ANC four or more visit coverage was only 43% and pentavalent 3 coverage was 55.2%.

Conclusion: The assessment revealed that the capacity of the Ethiopian PHC is limited in delivering quality health services, and its overall performance remains insufficient to progress towards achieving universal health coverage. The findings call for increasing funding for PHC, improving the availability of basic amenities at PHC units, strengthening logistics management system, designing, and implementing workforce development and motivation mechanisms and improving the availability and readiness of health services at health facilities.