Table 1

Anticipated strengths, challenges and possible strategies to support Ethiopian PHCG scale-up in relation to a framework for successful scale-up

StrengthsPotential challengesPotential strategies
Success factor for scale-up (domain): attributes of the intervention being scaled up
Simplifies existing clinical decision support.Guidance differs from previous training.

  • Integrate within PHC preservice training programmes.

Facilities not resourced to deliver the care outlined in PHCG.

  • Central Pharmaceuticals Fund and Supply Agency prepared to support implementation.

  • Monitor medication stock-outs closely.

Success factor for scale-up (domain 2): attributes of implementers
Working with non-state partners for technical support.Weak leadership at the district and PHC levels.

  • Link with existing transformation agenda to strengthen leadership.

Success factor for scale-up (domain 3): chosen delivery strategy

  • Phased implementation using a cascade model of training.

  • Decentralised through regions and zones.

  • Horizontal, integrative approach.

Lack of familiarity with peer-to-peer learning.

  • Pioneer programmes of clinical mentorship, for example, building on the successful models used for scale-up of task-shared HIV care and the Health Extension Programme.45

Success factor for scale-up (domain 4): attributes of the adopting community

  • PHCG is advantageous for the PHC worker and compatible with their core tasks.

  • PHC workers motivated by being able to deliver improved care to patients.

Unwillingness of PHC workers to consult the guideline during consultation.

  • Behavioural change communication strategies will be developed to inform patients why their providers will be consulting guidance.

  • Promotion of an all-learning culture during training.

  • Ultimately move towards using tablet-based versions of the guide.

Innovation of facility-based training may not be well-received because of benefits of off-site training.

  • District (‘woreda’) health office to recognise high-performing facilities.

  • Recognise training as part of continuing professional development.

Additional training may be needed to enable task-sharing for new areas of healthcare (non-communicable diseases/mental health) to health centre level.

  • Integrate PHCG into vertical programme inservice training (eg, the WHO Mental Health Gap Action Programme) and preservice training.

  • Expanding the database of training cases.

Sustainability: declining use and adherence to PHCG over time.

  • Institutionalise quality improvement (including clinical audit): ASSET to adapt and test.

  • Link PHCG adherence to performance incentive mechanisms and health insurance requirements.

  • Increase accountability to the community by strengthening the community-based Health Development Army and revitalisation of community clinical fora.

High turnover of rural health workers.

  • Work with the PHCG approach of building capacity to train health workers locally.

Success factor for scale-up (domain 5): sociopolitical context

  • Strong political leadership.

  • Strengthens core policy initiative.

  • Strong country ownership.

Change of leadership.Maintain the broad base for buy-in.
Success factor for scale-up (domain 6): research context

  • Collaboration with ASSET project increases chances of ‘learning by doing’.

  • Research may be perceived as slow and as an unrelated activity.

  • Build capacity in operational research.

  • Engage implementers in setting the research question.

  • Communicate research findings in a timely manner.

  • ASSET, heAlth Systems StrEngThening in sub-Saharan Africa; PHC, primary healthcare; PHCG, Primary Health Care Clinical Guidelines.