In put interaction
The results of scanning mission, developing shared vision, mobilizing financial, human and other resources entered into in the steps of collaboration have established an inputs interaction. The majority of the respondents believed that the shared missions, shared visions, interactions with partners and allocation of financial resources had a positive effect on accelerating the performances of primary health care units and the district health system.
One of the district health office heads had this to say: “…staff mobilization and deployment, allocation of budget for fuel, covering staff accommodation costs and sharing of resources in the twinning partnership assisted us to motivate staff and led to the achievement of our shared vision.” .” (011, District Health Office Head, BSc nurse, Tigray Region).
Similarly, the head of a health center expressed, “Our health center ran out of lab supplies for syphilis screening tests, and the ante-natal services were not complete for pregnant mothers. Similarly, our partner district reported an unusual increase in the number of malaria cases observed in health facilities, while they lack antimalaria drugs. Both of us benefited from the established relationship as we were able to share human resources and essential drugs and supplies.”(034, Health Center Director, BSc Nurse, Amhara Region).
Leadership
The capacity of the leadership on scanning their environment, focusing on impactful interventions, exhibiting motivating and inspiring behavior and mobilizing and aligning resources were pointed out as having a positive influence on the achievement of the twinning partnership projects. A health worker affirms that, “Assessing the needs and demands of the district health systems environment, mobilizing and aligning resources coupled with leaders’ recognition and acknowledgement of staff cemented commitment to the twinning partnership.” (017, Health Center Director, Health Officer, Tigray Region).
The majority of the respondents believed that the commitment of the assigned focal persons in planning, organizing, facilitating, implementing and monitoring the activities had a positive effect on the established partnerships. Almost all staff who were engaged in the twinning partnership were acknowledged by the top managers as having facilitated vehicles, per-diem and other resources effectively which led to the successful implementation of the developed twinning projects.
Formal roles and procedures
Each level of the healthcare system maintains a set of roles and responsibilities endorsed by partners ensuring the implementation of the twinning strategy at all level of health system. The majority of the respondents highlighted that the established clear structures, roles and responsibilities of all stakeholders helped them to achieve more results. One of the district health office managers had this to say: “The launching workshop showed us the structures, roles and responsibilities of the twinning partnership. We also defined and shared this at the district health office and health center level which was instrumental for effectively carrying out our twinning partnership planned activities.” (002, District Health Office Head, BSc Nurse , Oromia Region). Committed and willing districts and zone health departments signed a memorandum of understanding to work together for one full year.
Communication
During the implementation of the twinning partnership, projects members communicated with each other through various channels including telephone conversations, written communication, creating groups through mobile applications, and face to face communication. A health worker had this to say about improving performance of partners using telephone communication: “We usually we use telephone communication to arrange meetings, experience sharing events and to invite experts. This helped us to maintain our friendly relationship.” (012, Health Reform Core Process Owner, BA in Economics, Tigray Region).
Another health worker describes the importance of face to face communication supplemented by written letters on sharing of drugs and supplies: “If we are requesting drugs and supplies we used formal letters along with face-to-face communication.” (005, Head of Health Center Pharmacy Department, Pharmacy Technician, Oromia Region). The health manager explains how a mobile app was used to create groups for information sharing on performance of district health system. “We have a telegram [app] group where we update each other on our day-to-day performances.” (028, Maternal and Child Health expert, Health Officer, SNNP Region).
Another Health Center Staff had to say “Before we engaged in twinning partnership, our communication was limited within district health teams, no means to share experience and supporting each other with similar health facilities located in other districts. We used to meet during review meeting where we share and learn experiences and success. We also do not have means to organize learning tours to other primary health care facilities. Now, our health center [name] formally communicated with twinned health center located in [name] district.” (001, Health Center Director, Health Officer, Oromia Region)
Maintenance task
The basic twinning partnership training focus on our main chapters, namely, health sector priority, strategic problem solving, performance management and communication. During the implementation of the twinning partnership, the importance of clear reporting requirements and of sharing information were well addressed. One of the district health office staff had this to say: “During the basic twinning training, participants identified the current situation, developed desired measurable results, identified obstacles and prioritized solutions. In addition, a detailed action plan on resource mobilization as well as monitoring and evaluation was prepared. These activities helped us to share basic information and performance status.” (032, District Health Office Vice Head, BSc Nurse, Amhara Region)
Another staff had explained the proper maintenance task achievement as integrated with routine health system activities: “We organized supportive supervision, learning tours, and facilitated a number of workshop on Ethiopian Primary Health Care Alliance for Quality.” (023, Health Center Staff, Midwife, SNNP Region)
A health center staff also expressed his opinion on effective maintenance: “The staff facilitated onsite and off-site trainings, experience sharing events, common review meetings and expert exchange platforms.” (038, Health Center Quality Improvement Officer, master’s in public health, Amhara Region)
Outputs
Three major categories were discussed under outputs. First, the summary of additive results, then synergy and antagonistic results will be presented below.
Additive results
Additive results implied the implementation of health sector priority separately without considering the effect of implementing the twinning partnership. The majority twinning partnership targeted districts reported their engagement through orientation of health sector reforms, facilitated self-assessment against standards and provide routine health services. A district health office head said: “ …the health office organizes and facilitates orientation of health sector reforms.” (011, District Health Office Head, BSc nurse, Tigray Region).
Another health worker had this to say about the routine activities in their office implemented regularly: “Every quarter, the performance management team assesses performance against the standards.” (001, Health Center Director, Health Officer, Oromia Region)
A health worker describes the additive results of the established twinning partnership saying; “… though we had relatively higher performances than our partner low performer district within the partnership, we heard about experiences of implementing challenging interventions from our twin woreda, [name]. We also adopted the best practices and collected the list of items essential for maternal waiting homes and audio-visual job aids.” (034, Health Center Director, BSc Nurse, Amhara Region).
All twinning partnership targeted districts were rated on three occasions; namely, baseline, mid-term and end-line stages. Fig. 2. below depicts that six and two districts were categorized as low and medium performers at baseline measurement, respectively. These scores were improved at mid-term as two, two and four districts categories as high, medium and low performing districts, respectively. The end-line results revealed that out of eight districts, three fulfilled district the transformation criteria, three were categorized as medium performers and the remaining two districts despite improving the scores, fell in the low performing districts category. Both low and medium performing districts benefited from the implemented twinning partnership strategy which reinforces the argument that these achievements would have come about without the twinning partnership exercises.
Antagonistic results
Despite the additive results and synergy observed among partnering districts, there were some observed antagonistic results. During the experience sharing events as well as while conducting integrated supportive supervisions, some staff did not know the reason for the established partnership and the investment appeared to them as a waste of resources.
“While we were motivated to share our knowledge and skills to partner district staff, they perceived us as having travelled over 90 kilometers to get financial rewards form our meals and accommodation expense payouts.” (032, District Health Office Vice Head, BSc Nurse, Amhara Region)
Some of health the workers pointed out that lack of transparency in decision making and lack inclusion of all departments in the established twinning partnership had a negative impact on achievements. Furthermore, they describe the demotivating effects of lack of good governance on collaborative efforts.
“I was one of the active participants in the development of the one-year twinning project. However, it was not clear to some of us the process through which leaders and managers hand-picked staff for the experience sharing events….” .” (005, Health Center Pharmacy Head, Pharmacy Technician, Oromia Region)