Volume 94, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



In 2004, Ethiopia introduced a community-based Health Extension Program to deliver basic and essential health services. We developed a comprehensive performance scoring methodology to assess the performance of the program. A balanced scorecard with six domains and 32 indicators was developed. Data collected from 1,014 service providers, 433 health facilities, and 10,068 community members sampled from 298 villages were used to generate weighted national, regional, and agroecological zone scores for each indicator. The national median indicator scores ranged from 37% to 98% with poor performance in commodity availability, workforce motivation, referral linkage, infection prevention, and quality of care. Indicator scores showed significant difference by region ( < 0.001). Regional performance varied across indicators suggesting that each region had specific areas of strength and deficiency, with Tigray and the Southern Nations, Nationalities and Peoples Region being the best performers while the mainly pastoral regions of Gambela, Afar, and Benishangul-Gumuz were the worst. The findings of this study suggest the need for strategies aimed at improving specific elements of the program and its performance in specific regions to achieve quality and equitable health services.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. FMOH, 2008. Health Sector Development Plan, 2005/6–2010/11, Mid-Term Review. Addis Ababa, Ethiopia: Federal Ministry of Health. [Google Scholar]
  2. Chan M, , 2008. Return to Alma-Ata. Lancet 372: 865866.[Crossref] [Google Scholar]
  3. Teklehaimanot HD, Teklehaimanot A, , 2013. Human resource development for a community-based health extension program: a case study from Ethiopia. Hum Resour Health 11: 39.[Crossref] [Google Scholar]
  4. FMOH, 2010. Health Sector Development Program (IV), 2010/11–2014/15. Addis Ababa, Ethiopia: Federal Ministry of Health. [Google Scholar]
  5. FMOH, 2007. Health Extension Program in Ethiopia. Addis Ababa, Ethiopia: Federal Ministry of Health. [Google Scholar]
  6. Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, Pielemeier NR, Mills A, Evans T, , 2004. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet 364: 900906.[Crossref] [Google Scholar]
  7. Lavis JN, Posada FB, Haines A, Osei E, , 2004. Use of research to inform public policymaking. Lancet 364: 16151621.[Crossref] [Google Scholar]
  8. Sebastian MS, Lemma H, , 2010. Efficiency of the health extension programme in Tigray, Ethiopia: a data envelopment analysis. BMC Int Health Hum Rights 10: 16.[Crossref] [Google Scholar]
  9. Gauld R, Al-wahaibi S, Chisholm J, Crabbe R, Kwon B, Oh T, Palepu R, Rawcliffe N, Sohn S, , 2011. Scorecards for health system performance assessment: the New Zealand example. Health Policy 103: 200208.[Crossref] [Google Scholar]
  10. Inamdar N, Kaplan RS, Bower M, , 2002. Applying the balanced scorecard in healthcare provider organizations. J Healthc Manag 47: 179195, discussion 195–196. [Google Scholar]
  11. Inamdar SN, Kaplan RS, Jones ML, Menitoff R, , 2000. The Balanced Scorecard: a strategic management system for multi-sector collaboration and strategy implementation. Qual Manag Health Care 8: 2139.[Crossref] [Google Scholar]
  12. Kaplan RS, Norton DP, , 1992. The balanced scorecard—measures that drive performance. Harv Bus Rev 70: 7179. [Google Scholar]
  13. Klassen A, Miller A, Anderson N, Shen J, Schiariti V, O'Donnell M, , 2010. Performance measurement and improvement frameworks in health, education and social services systems: a systematic review. Int J Qual Health Care 22: 4469.[Crossref] [Google Scholar]
  14. Peters DH, Noor AA, Singh LP, Kakar FK, Hansen PM, Burnham G, , 2007. A balanced scorecard for health services in Afghanistan. Bull World Health Organ 85: 146151.[Crossref] [Google Scholar]
  15. Zelman WN, Pink GH, Matthias CB, , 2003. Use of the balanced scorecard in health care. J Health Care Finance 29: 116. [Google Scholar]
  16. Edward A, Kumar B, Kakar F, Salehi AS, Burnham G, Peters DH, , 2011. Configuring balanced scorecards for measuring health system performance: evidence from 5 years' evaluation in Afghanistan. PLoS Med 8: e1001066.[Crossref] [Google Scholar]
  17. Chan GJ, Parco KB, Sihombing ME, Tredwell SP, O'Rourke EJ, , 2010. Improving health services to displaced persons in Aceh, Indonesia: a balanced scorecard. Bull World Health Organ 88: 709712.[Crossref] [Google Scholar]
  18. Hansen PM, Peters DH, Niayesh H, Singh LP, Dwivedi V, Burnham G, , 2008. Measuring and managing progress in the establishment of basic health services: the Afghanistan health sector balanced scorecard. Int J Health Plann Manage 23: 107117.[Crossref] [Google Scholar]
  19. Rabbani F, Jafri SM, Abbas F, Pappas G, Brommels M, Tomson G, , 2007. Reviewing the application of the balanced scorecard with implications for low-income health settings. J Healthc Qual 29: 2134.[Crossref] [Google Scholar]
  20. Rabbani F, Jafri SM, Abbas F, Shah M, Azam SI, Shaikh BT, Brommels M, Tomson G, , 2010. Designing a balanced scorecard for a tertiary care hospital in Pakistan: a modified Delphi group exercise. Int J Health Plann Manage 25: 7490.[Crossref] [Google Scholar]
  21. ten Asbroek AH, Arah OA, Geelhoed J, Custers T, Delnoij DM, Klazinga NS, , 2004. Developing a national performance indicator framework for the Dutch health system. Int J Qual Health Care 16 (Suppl 1): i65i71.[Crossref] [Google Scholar]
  22. Datiko DG, Lindtjorn B, , 2009. Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS One 4: e5443.[Crossref] [Google Scholar]
  23. Karim AM, Admassu K, Schellenberg J, Alemu H, Getachew N, Ameha A, Tadesse L, Betemariam W, , 2013. Effect of Ethiopia's health extension program on maternal and newborn health care practices in 101 rural districts: a dose-response study. PLoS One 8: e65160.[Crossref] [Google Scholar]
  24. King JD, Endeshaw T, Escher E, Alemtaye G, Melaku S, Gelaye W, Worku A, Adugna M, Melak B, Teferi T, Zerihun M, Gesese D, Tadesse Z, Mosher AW, Odermatt P, Utzinger J, Marti H, Ngondi J, Hopkins DR, Emerson PM, , 2013. Intestinal parasite prevalence in an area of Ethiopia after implementing the SAFE strategy, enhanced outreach services, and health extension program. PLoS Negl Trop Dis 7: e2223.[Crossref] [Google Scholar]
  25. Medhanyie A, Spigt M, Kifle Y, Schaay N, Sanders D, Blanco R, Geertjan D, Berhane Y, , 2012. The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study. BMC Health Serv Res 12: 352.[Crossref] [Google Scholar]
  26. Yitayal M, Berhane Y, Worku A, Kebede Y, , 2014. The community-based Health Extension Program significantly improved contraceptive utilization in West Gojjam Zone, Ethiopia. J Multidiscip Healthc 7: 201208.[Crossref] [Google Scholar]
  27. Kringos DS, Boerma WG, Hutchinson A, van der Zee J, Groenewegen PP, , 2010. The breadth of primary care: a systematic literature review of its core dimensions. BMC Health Serv Res 10: 65.[Crossref] [Google Scholar]
  28. Kringos DS, Boerma WG, Bourgueil Y, Cartier T, Hasvold T, Hutchinson A, Lember M, Oleszczyk M, Pavlic DR, Svab I, Tedeschi P, Wilson A, Windak A, Dedeu T, Wilm S, , 2010. The European primary care monitor: structure, process and outcome indicators. BMC Fam Pract 11: 81.[Crossref] [Google Scholar]
  29. Kruk ME, Freedman LP, , 2008. Assessing health system performance in developing countries: a review of the literature. Health Policy 85: 263276.[Crossref] [Google Scholar]
  30. Campbell SM, Braspenning J, Hutchinson A, Marshall M, , 2002. Research methods used in developing and applying quality indicators in primary care. Qual Saf Health Care 11: 358364.[Crossref] [Google Scholar]
  31. Bosch-Capblanch X, Garner P, , 2008. Primary health care supervision in developing countries. Trop Med Int Health 13: 369383.[Crossref] [Google Scholar]
  32. Brugha R, Starling M, Walt G, , 2002. GAVI, the first steps: lessons for the Global Fund. Lancet 359: 435438.[Crossref] [Google Scholar]
  33. WHO, 2001. Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health. Geneva, Switzerland: World Health Organization. [Google Scholar]
  34. Donabedian A, , 1980. Methods for deriving criteria for assessing the quality of medical care. Med Care Rev 37: 653698. [Google Scholar]
  35. Chen LC, , 2010. Striking the right balance: health workforce retention in remote and rural areas. Bull World Health Organ 88: 323A.[Crossref] [Google Scholar]
  36. Kitaw Y, Ye-Ebiyo Y, Said A, Desta H, Teklehaimanot A, , 2007. Assessment of the training of the first intake of health extension workers. Ethiop J Health Dev 21: 232239. [Google Scholar]
  37. Mutale W, Ayles H, Bond V, Mwanamwenge MT, Balabanova D, , 2013. Measuring health workers' motivation in rural health facilities: baseline results from three study districts in Zambia. Hum Resour Health 11: 8.[Crossref] [Google Scholar]
  38. Olsen OE, Ndeki S, Norheim OF, , 2005. Human resources for emergency obstetric care in northern Tanzania: distribution of quantity or quality? Hum Resour Health 3: 5.[Crossref] [Google Scholar]
  39. Yitayal M, Berhane Y, Worku A, Kebede Y, , 2014. Health extension program factors, frequency of household visits and being model households, improved utilization of basic health services in Ethiopia. BMC Health Serv Res 14: 156.[Crossref] [Google Scholar]
  40. Banteyerga H, , 2011. Ethiopia's health extension program: improving health through community involvement. MEDICC Rev 13: 4649.[Crossref] [Google Scholar]
  41. Bruni RA, Laupacis A, Martin DK, University of Toronto Priority Setting in Health Care Research Group, , 2008. Public engagement in setting priorities in health care. CMAJ 179: 1518.[Crossref] [Google Scholar]
  42. Rosato M, Laverack G, Grabman LH, Tripathy P, Nair N, Mwansambo C, Azad K, Morrison J, Bhutta Z, Perry H, Rifkin S, Costello A, , 2008. Community participation: lessons for maternal, newborn, and child health. Lancet 372: 962971.[Crossref] [Google Scholar]
  43. Arah OA, Westert GP, Hurst J, Klazinga NS, , 2006. A conceptual framework for the OECD Health Care Quality Indicators Project. Int J Qual Health Care 18 (Suppl 1): 513.[Crossref] [Google Scholar]
  44. Donabedian A, , 1988. The quality of care. How can it be assessed? JAMA 260: 17431748.[Crossref] [Google Scholar]
  45. FMOH, 2010. Health and Health Related Indicators of Ethiopia. Addis Abab, Ethiopia: Federal Ministry of Health. [Google Scholar]
  46. WHO, 2005. Immunization Coverage Cluster Survey: Reference Manual. WHO/IVB/04.23. Geneva, Switzerland: World Health Organization. [Google Scholar]
  47. DiStefano C, Zhu M, Mindrila D, , 2009. Understanding and using factor scores: considerations for the applied researcher. Pract Assess Res Eval 14: 111. Available at: http://pareonline.net/getvn.asp?v=14&n=20. [Google Scholar]
  48. Singh RP, Nath S, Prasad SC, Nema AK, , 2008. Selection of suitable aggregation function for estimation of aggregate pollution index for river Ganges in India. J Environ Eng 134: 689701.[Crossref] [Google Scholar]
  49. Grice JW, Harris RJ, , 1998. A comparison of regression and loading weights for the computation of factor scores. Multivariate Behav Res 33: 221247.[Crossref] [Google Scholar]
  50. Jollands N, Lermit J, Patterson M, , 2003. The Usefulness of Aggregate Indicators in Policy Making and Evaluation: A Discussion with Application to Eco-Efficiency Indicators in New Zealand. Available at: http://een.anu.edu.au/wsprgpap/papers/jolland1.pdf. [Google Scholar]
  51. Wooldridge JM, , 2003. Cluster-sample methods in applied econometris. Am Econ Rev XCIII: 133138.[Crossref] [Google Scholar]
  52. Kelbessa Z, Baraki N, Egata G, , 2014. Level of health extension service utilization and associated factors among community in Abuna Gindeberet District, West Shoa Zone, Oromia Regional State, Ethiopia. BMC Health Serv Res 14: 324.[Crossref] [Google Scholar]
  53. Negusse H, McAuliffe E, MacLachlan M, , 2007. Initial community perspectives on the Health Service Extension Programme in Welkait, Ethiopia. Hum Resour Health 5: 21.[Crossref] [Google Scholar]
  54. Birhanu Z, Godesso A, Kebede Y, Gerbaba M, , 2013. Mothers' experiences and satisfactions with health extension program in Jimma zone, Ethiopia: a cross sectional study. BMC Health Serv Res 13: 74.[Crossref] [Google Scholar]
  55. WISP, 2008. Pastoralism in Ethiopia: Its Total Economic Values and Development Challenges. Addis Ababa, Ethiopia: SOS Sahel Ethiopia, World Initiative for Sustainable Pastoralism. [Google Scholar]
  56. Dubale T, Mariam DH, , 2007. Determinants of conventional health service utilization among pastoralists in northeast Ethiopia. Ethiop J Health Dev 21: 142147.[Crossref] [Google Scholar]

Data & Media loading...

Supplementary Appendix

  • Received : 11 Mar 2015
  • Accepted : 21 Jan 2016
  • Published online : 04 May 2016

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error