Networks of care for optimizing Primary Health Care Service Delivery in Ethiopia: Enhancing relational linkages and care coordination.

Introduction: Ethiopia has made notable progress in reducing maternal and perinatal mortality, yet challenges remain in meeting the 2030 Sustainable Development Goals. Persistent issues such as low service utilization, coupled with poor quality, fragmented care, and ineffective referral systems hinder progress. The "Improve Primary Health Care Service Delivery (IPHCSD)" project, implemented by JSI and Amref Health Africa since April 2022, seeks to address these gaps through a Networks of Care (NoCs) approach. This paper describes the lessons learned from implementing the NoCs approach to optimize primary health care in Ethiopia.

Methods: The project incorporates embedded implementation science, guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Key implementation strategies co-designed included strengthening community engagement, establishing NoCs, and introducing quality improvement initiatives using the Model for Improvement. Routine program monitoring data, NoCs process evaluation, and facility service statistics were utilized for this study. Service statistics were analyzed using Student's t-test and interrupted time-series analysis to compare maternal and child care outcomes before and after the NoCs intervention, with counterfactual estimates generated to assess the intervention's impact. Qualitative data from key informant interviews were transcribed, coded, and analyzed to identify themes and patterns using Atlas.ti.

Results: The NoCs approach has significantly enhanced relational linkages between primary health care facilities and health care providers, fostering stronger collaboration and communication. This has fostered trust, improved care coordination, optimized primary health care performance, and increased health service utilization within woreda health systems. The interrupted time series analysis indicated that the rate of ANC 8+ visits was 29.8% per month higher than expected without the NoCs strategy (Coef: 2.39; p-value < 0.01) and an 18.4% increase in obstetric complications managed (Coef: 1.71; p-value = 0.050), with a 43% overall increase. Perinatal mortality decreased by 34%, from 31.3 to 20.1 per 1,000 births [t-test: 2.12; p-value: 0.040)].

Conclusion: The NoCs approach in Ethiopia has proven effective in enhancing the relational elements, care coordination, and quality of primary health care services, leading to better maternal and child health outcomes. The findings expand the existing body of research on NoCs implementation best practices and further confirm that it provides a scalable model for strengthening health services in low-resource settings.