Twinning Partnership Program to Strengthen Primary Health Care (PHC) in Ethiopia

(2020 – Present)

AIHA has been creating twinning partnerships to help build lasting health system capacity since 1992. In 2022, a team of 10 from Ethiopia traveled to Australia where they learned about existing models of primary care, educational design, and operational research. We showcased this project at the International Conference on Primary Health Care in Addis Ababa, September 5-7, 2023.

In November 2020, AIHA launched our fourth project in Ethiopia supported by the Gates Foundation. Initially a two-year project that has been extended through 2024, the partnership’s goal is to build the capacity of the International Institute for Primary Health Care – Ethiopia (IPHC-E) to serve as both a national and regional resource for the delivery of quality primary health care service for essential, curative, and preventive services in Ethiopia.

The IPHC-E was established by the Federal Ministry of Health (FMOH) to strengthen Ethiopia’s primary health care (PHC) system in the context of achieving universal health coverage (UHC) and meeting the Sustainable Development Goals (SDGs) for health. It does this by serving as a global resource for PHC, building capacity through training and information sharing, carrying out health systems implementation research, and contributing to the global advocacy for UHC through primary health care. It is envisioned that the Institute will be transformed into a Center of Excellence in PHC Training, Advocacy, and Evidence Generation and ultimately serve as the first WHO Collaborative Center for PHC on the African continent.

Context and Background

In Ethiopia, the FMOH’s flagship and innovative community-based program deployed to achieve PHC goals is the Health Extension Program (HEP). The HEP plays a critical role by working with – and within – communities to help them acquire the knowledge and skills they need to enable them to ensure their own wellbeing. HEP aims to improve equitable access to basic care and preventive health services that are locally based and readily accessible to everyone. These services all have a strong focus on health promotion and preventive health activities, as well as increased community involvement.

Despite the improvements in health outcomes achieved through implementing HEP, Ethiopia – and other countries in Africa – are still facing challenges in designing and implementing PHC and improving health services for their respective populations. In Ethiopia, this includes sub-optimal PHC policy design, implementation challenges, a piecemeal approach, selective PHC with limited impact on health outcomes at the population level, and suboptimal community ownership and engagement.

A national assessment of the Ethiopian Health Extension Program (FMOH, 2019) revealed that PHC units lack the necessary infrastructure and practices, which has negatively impacted the quality of care and customer satisfaction. Different studies also identified gaps in the competency of Health Extension Workers, who are critical to an effective HEP. Part of the shortcomings of the Health Extension Workers and, thus, the HEP can be traced back to inadequate training. Evaluations in Ethiopia have shown that training curricula, though relevant, were not fully implemented. Additionally, the trainee recruitment process failed to ensure that the candidates met the required language and other competencies. Recommendations for improvement included promoting stakeholder collaboration to improve training and strengthening linkage among PHC units.

Project Design

To meet these challenges, the IPHC-E needs an internationally standardized training curriculum that will equip trainers and mentors to adequately and effectively train more PHC professionals. In furtherance of the IPHC-E’s goal of becoming a Center of Excellence for PHC training, this project was designed to build the capacity of the IPHC-E staff and trainers to develop new and strengthen existing training curricula that will meet international standards of quality PHC training.

In addition, human resources are essential building blocks of any healthcare system, including PHC and HEP. Attrition and demotivation are common challenges in the provision of PHC in developing countries, including Ethiopia. A system of introducing efficient human resources management for PHC is critical for success. Strengthening the leadership, management, and governance of the PHC system as part of the project design is helping to make the approach more sustainable and outcome-oriented.

AIHA is co-implementing this project with Johns Hopkins University (JHU) to best support the IPHC-E and strengthen its institutional and human resource capacity through a broad matrix of technical assistance. Stakeholders devised a strategy for transforming the existing PHC system on a national and regional level. The project supports the implementation plan and has established a phase-based approach and resources necessary for a comprehensive PHC delivery system that can be achieved in five years during which time the IPHC-E is expected to become a fully functional and independent entity.

The project is strengthening the training programs for healthcare providers to improve Ethiopia’s PHC system as well as contributing to the effective implementation of continuous capacity-building programs for health sector leaders at different levels. It is training human resources for health not only to provide critical health care services, but also to become change agents in the PHC system.

UQ partners visit a Health Post in Ethiopia to review clinical protocols with their counterparts.

Drawing on our 30+ years of experience implementing twinning partnerships to effectively and sustainably develop institutional and human resource capacity, AIHA engaged the University of Queensland (UQ) in Brisbane, Australia, to provide technical assistance and support to IPHC-E. Through this partnership, we worked with JHU and other stakeholders to transform the existing system into one that complies with modern criteria for UHC by supporting the provision of technical assistance and training for IPHC-E staff in pedagogy, research, and evidence-based PHC practices, among other things. This has allowed the institution to have its own pool of trainers that are fully able to take over training activities moving forward.

AIHA’s Focus Areas

AIHA and JHU are working collaboratively alongside the IPHC-E, with our specific interventions focused on leveraging our hallmark twinning model and existing partnerships, networks, and experience to build the capacity of the IPHC-E at the national and regional level in technical areas identified during the initial needs assessment. Namely, AIHA helped establish processes and systems for sharing best practices and lessons learned; improved human resource training capacity; and supported the IPHC-E’s efforts to become a WHO Collaborating Center for Primary Health Care.

With the assistance of AIHA’s twinning partner, the University of Queensland, the project provided technical assistance to fill the gap in designing standardized training curricula as well as provide TOTs on selected topics, such as maternal and child health, behavior change communication, health education, and communications. The specific trainings were selected based on an assessment of existing policies, infrastructure, and service delivery practices.

AIHA supported rolling out and scaling up the capacity of the selected core trainers and strengthening the identified six PHC hubs, empowering them to can carry on the trainings in the future. Specifically, and consistent with the IPHC-E’s strategic plan, AIHA’s role focused on:

Reviewing and strengthening PHC strategy and training curricula with emphasis on “soft skills” and adult learning methodology, strengthening training programs for Ethiopian PHC providers by enhancing skills and competencies of a multi-disciplinary team of trainers, increasing the number of PHC professional trainers, and supporting technical assistance and training for IPHC-E staff on pedagogy.
Using the established partnerships, adaptation, and dissemination of best international practices and approaches in strengthening the core multi-disciplinary group of master trainers on a national and regional level.
Strengthening IPHC’s functionality at the national level – by establishing six PHC hubs hosted at RHBs, universities, or regional hospitals to support and replicate the PHC training in the selected regions. These groups of professionals have been instrumental in linking the institutions with the regions.
Providing technical assistance for developing and accreditation IPHC as a WHO Collaborating Center in PHC.

Applying AIHA’s twinning partnership model to these workstreams created a dynamic, comprehensive, and integrated capacity-building effort that strengthened IPHC-E to provide continuous education, training, and sustainable information resources. While the highest priority of this project was to strengthen the capacity of the Institute and its six PHC hubs to provide services in support of quality PHC, our core mission was to develop faculty and institutionalize training capacity in a manner that is ultimately sustainable.

Project Accomplishments

Through November 2024 when the twinning partnership concluded its work, key accomplishments included:

In collaboration with IPHC-E and key stakeholders, AIHA engaged consultants who conducted a needs assessment, focusing on identifying training gaps, reviewing current policies and infrastructure, service delivery, leadership capacity, and other areas. The assessment identified several gaps, which led the team to develop and issue the Terms of Reference that helped us engage the University of Queensland to be a twinning partner and to help address these gaps.
Multiple regional hub site assessments were conducted, sites were selected, and candidates for the TOT training course were identified.
To strengthen IPHC-E capacity, our UQ partners provided a six-week training on program and project cycle management, including monitoring and evaluation, for the IPHC-E team.
AIHA conducted a PHC Hub planning meeting in January 2023 attended by 29 participants drawn from the PHC hubs and IPHC-E staff. The main objective of the meeting was to get buy-in on the importance of PHC hubs, which are satellite sites for the IPHC-E. Coordinators and volunteers agreed that the hubs are essential to ensure sustainability, better integrate workstreams, enhance coverage, and create resilience around Ethiopia’s PHC system. In addition, it was agreed that PHC hubs needed to strengthen leadership capabilities among their staff to continue this work of the partnership into the future. AIHA engaged volunteers drawn from regional health bureaus, health science colleges, universities, and more to ensure different perspectives were included in every aspect of efforts to cascade training throughout the regions.
As part of the PHC system strengthening support provided by the UQ team, an initial PHC TOT was provided to 32 participants from FMOH, RHBs, and IPHC-E staff. Following this training conducted by the UQ team, PHC Basic Training was cascaded by PHC Hub coordinators from Jimma University (26 trained); Arba Minch University in Hawassa (29 trained); and Bahir Dar University (29 trained).
The advocacy team also cascaded the Public Health and PHC Advocacy Training using a blended approach that featured virtual and face-to-face sessions. The virtual session ran with the three identified hubs: Bahir Dar University, Jimma University, and Arba Minch University. Following the virtual modality, face-to-face training was provided for 55 trainees, who fulfilled all the requirements and took part in the trainings. Based on these sessions, strengthening knowledge management for the PHC Hubs and developing a networking platform to enhance the research practice among RHBs, universities, and health science colleges via the hubs was identified as one of the gaps that AIHA and our partners worked to overcome by procuring necessary equipment, such as servers, computers, and scanners, as well as recruiting IT professionals and librarians.
As part of the strategy to strengthen IPHC-E and Ethiopia’s PHC system, the UQ team delivered virtual trainings, including an M&E training for 17 IPHC-E and PHC hub participants; a Quality Improvement training for 19 participants; and a Systematic Review (SR) and Policy Analysis for 20 participants and, as an output, eight SR topics were identified and are currently in manuscript stage, while a total of five articles have thus far been published: 1) Beyond Astana: Configuring the WHO CC for PHC; 2) Multi-sectoral Actions in Primary Health Care: A Realist Synthesis of a Scoping Review; 3) Digital Health Interventions to Improve Access to and Quality of PHC Services: A Scoping Review; 4) Successes and Challenges Towards Improving Quality of PHC: A Scoping Review; and 5) Continuity and Care Coordination of PHC: A Scoping Review.
Conducted three initial partnership exchanges for the purpose of sharing ideas, seeing and learning from best practices, and adapting them to the Ethiopian context: 1) May 2022 – a team from UQ to Ethiopia; 2) August 2022 – a team from Ethiopia and UQ to Cambodia and Thailand; and 3) September 2022 – a team from Ethiopia to Brisbane, Australia.

Scenes from the Ethiopia PHC twinning partnership activities and study tours.

The IPHC-E and UQ team conducted a gender equity assessment with ethical clearance, data collection and analysis, and technical assistance provided by experts from UQ.
The project supported grant writing training and technical assistance for IPHC-E staff and PHC Hub coordinators.
AIHA and the IPHC-E team selected a Marketing Strategy Consultant that helped develop and deliver an organizational communications and marketing strategy document for IPHC-E.
AIHA facilitated experience-sharing visits to selected countries to help IPHC-E become a strong independent institute and reach its goal of becoming a WHO collaboration center. These included study tours to South Africa in July 2023, Europe (Belgium and Switzerland) in October 2023, and Vietnam in July-August 2024.
In January 2023, AIHA conducted a PHC Study Tour Experience Sharing Workshop to share best practices and lessons learned from the Thailand, Cambodia, and Australian health systems. The tours and this meeting targeted key staff from the Ethiopian FMOH to brainstorm how to most effectively replicate the best practices in the Ethiopian PHC context and system. These lessons are also being used as a benchmark to strengthen development of the Ethiopian PHC strategic framework. The meeting included 34 participants from the FMOH State Minister’s Office and PHC directorate, IPHC-E staff, PHC Hub coordinators and volunteers, and the AIHA team.
AIHA cosponsored the 2023 International Conference on Primary Health Care, which was conducted by the Federal Ministry of Health and the IPHC-E September 5-7 in Addis Ababa. Staff and partners showcased this project, as well as our Leadership Incubation Program for Health during the event, which drew more than 500 primary health care practitioners and policymakers from some 50 countries spanning the globe. Click here to read more about this event and here for the conference preview.
By the conclusion of the partnership in November 2024, the team had developed and piloted 28 training courses on various aspects of primary health care as detailed in the graphic below.

Testimonials from Twinning Partners

At the conclusion of the partnership, a number of individuals involved with the partnership provided their insight and perspectives on the impact of their collaboration, as well as key challenges they faced and work that still needs to be done. These included IPHC-E Director of Programs Anteneh Zewdie, IPHC-E National PHC Program Lead Eskinder Wolka, IPHC-E Advocacy Communications Lead Luidina Hailu, IPHC-E Knowledge Management Lead Emebet Zerfu, and Associate Professor Yibeltal Alemu of the University of Queensland School of Public Health.

To read an article summing up the work of the partnership, click here.

Updated April 28, 2025.