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. Last year, 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 Bill & Melinda Gates Foundation (BMGF). 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. 



The Project 

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. 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.

AIHA and our twinning partners at the University of Queensland (UQ) in Brisbane, Australia, have been working 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. 

UQ partners visiting Health Post in Ethiopia reviewing clinical protocols and chatting with their counterparts

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 is helping establish processes and systems for sharing best practices and lessons learned; improving human resource training capacity; and supporting 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 is providing 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 current policies, existing infrastructure, and service delivery. 

AIHA has been 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 has 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 has created a dynamic, comprehensive, and integrated capacity-building effort that strengthens the Institute to provide continuous education, training, and sustainable information resources. 

While the highest priority of this project is to strengthen the capacity of the Institute and its six PHC hubs to provide services in support of quality PHC, our core mission is to develop faculty and institutionalize training capacity in a manner that is ultimately sustainable.  



Project Accomplishments

  • 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 have been conducted, sites have been selected, and trainees that will take the TOT training course have been identified.
  • To strengthen the IPHC-E capacity, UQ  has provided a six-week training on program/project cycle management, including monitoring and evaluation for the IPHC-E team.
  • A PHC Hub planning meeting was conducted in January 2023 with 29 participants that came from PHC hubs, AIHA, UQ, and IPHCE staff. The main topic of the meeting was to get buy-in on the importance of PHC hubs. Coordinators and volunteers agreed that they are essential to ensure sustainability, better integrate workstreams, enhance coverage, and create resilience around PHC. The PHC hubs are considered to be satellite sites for the IPHC-E. In addition, it was agreed that PHC hubs need to strengthen their leadership capabilities to continue this partnership beyond this project to engage volunteers from different perspectives, such as regional health bureaus, health science colleges, universities, etc. It was also agreed that these volunteers need to be involved in every aspect of the cascading work.
  • As part of the PHC system strengthening support provided by the UQ team, PHC TOT was provided to 32 participants from FMOH, RHBs, and IPHC-E staff. Following the PHC TOT conducted by the UQ team, PHC Basic Training was cascaded by the following three PHC hub coordinators:
    • Jimma University PHC Hub (26 trained). 
    • Arba Minch University PHC Hub in Hawassa (29 trained). 
    • Bahir Dar University PHC Hub (29 trained). 
  • The Advocacy team also cascaded the Public Health and PHC Advocacy Training using a blended approach (virtually and face-to-face). 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. Strengthening knowledge management for PHC Hubs and networking the research practice among RHBs, universities, and health science colleges via hubs is one of the identified gaps that AIHA and our partners have been working to overcome by procuring necessary equipment, such as servers, computers, and scanners, as well as recruiting IT professionals and librarians. Consequently, we anticipate that significant PHC data will be collected and made available publicly in the near future.
  • As part of the strategy to strengthen IPHC-E and Ethiopia’s PHC system, a UQ team delivered virtual systematic review and policy brief analysis trainings:
    • Systematic Review (SR) and Policy Analysis for 20 participants from PHC hubs and IPHC-E, and as an output, eight SR topics were identified, and review documents are being prepared to be presented to UQ partners in the summer of 2023; 
    • M&E training for 17 participants; and
    • QI training for 19 participants.
  • UQ experts drafted a proposal and tools for gender equity assessments, which were shared with the IPHC-E technical working group for feedback prior to submission for the ethical clearance process to EPHA in Addis Ababa.
  • Conducted three study tours for the purpose of exchanging ideas, seeing and learning from best practices, and adapting them to the Ethiopian context: 
    • May 2022 – a team from UQ to Ethiopia
    • August 2022 – a team from Ethiopia and UQ to Cambodia and Thailand
    • September 2022 – a team from Ethiopia to Brisbane, Australia

Ethiopian delegates (IPHC-E, AIHA, University representatives) meeting their colleagues in Cambodia 

Ethiopian delegates (AIHA, IPHC-E, University representatives) visiting UQ partners

  • In January 2023, the PHC Study Tour Experience Sharing meeting was conducted based on the lessons learned from the Thailand, Cambodia, and Australian health systems. The tours and this meeting targeted key staff from the Ethiopian FMOH in order to discuss how to replicate the best practices in the Ethiopian PHC context/system. It is also believed these lessons will be used as a benchmarking to strengthen the Ethiopian PHC strategic framework development. The meeting had 34 participants from the FMOH State Minister’s office and PHC directorate, IPHC-E staff, AIHA, PHC hub coordinators, and their volunteers. 
  • 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.

    “Primary Health Care with a wholistic ideology of comprehensive and accessible health services for all is the goal of our deliberations in this conference,” Minister of Health of Ethiopia Dr. Lia Taddesse stated in her opening remarks at the International Conference on Primary Health Care. “Primary Health Care serves as a foundation of any health care system and its significance cannot be overstated,” she continued.


Upcoming Activities

  • IPHCE and PHC Hub teams will conduct systematic reviews and policy analysis on selected practices.
  • Host the UQ team in Ethiopia to evaluate the systematic review findings with PHC Hubs and support their publications.
  • Organize supportive supervision visits to the six PHC Hubs.
  • Conduct a gender equity assessment: ethical clearance, data collection and analysis, and technical assistance to be provided by UQ.
  • Conduct an additional cohort of an advocacy TOT.
  • Grant writing training and support for IPHC-E, AIHA, and PHC hubs coordinators. 
  • Conduct experience-sharing visits to selected countries that could help IPHC-E become a strong independent institute and reach its goal of becoming a WHO collaboration center.  
  • The IPHC and AIHA team is in the final stages of selecting a Marketing Strategy Consultancy firm to help IPHC-E develop the marketing strategy document.