WOREDA TRANSFORMATION

IN HEALTH
IMPLEMENTATION MANUAL
(REVISED)

Table of Contents
Acronym......................................................................................................................................................3
1. Introduction.........................................................................................................................................4
1.1. Situational analysis of Woreda Transformation..........................................................................................5
1.2. The scope of Woreda Transformation in HSTP-II........................................................................................7
1.3. Rationale.....................................................................................................................................................9

Section Two:..............................................................................................................................................11
Woreda transformation implementation approach..................................................................................11
in HSTP-II...................................................................................................................................................11
2.1. Goals and Objectives of Woreda Transformation in HSTP-II...........................................................................12
2.2. Definition of concepts...............................................................................................................................13
2.3. Woreda Transformation towards Universal Health Coverage..................................................................14
2.4. Investment/Intervention areas.................................................................................................................15

3. Performance Management for Woreda Transformation...................................................................18

3.1. Performance Review Mechanisms (PRM).............................................................................................22
3.2. Performance measurement indicators.................................................................................................22
3.3. Verification processes and Criteria.......................................................................................................25
3.3.1. Verification processes......................................................................................................................25
3.3.2. Verification Criteria..........................................................................................................................27
3.4. Recognition mechanisms......................................................................................................................28

4. Implementation Arrangement...........................................................................................................28
5. Roles and responsibilities of different stakeholders.....................................................................................34
5.1. Roles and responsibilities of FMOH......................................................................................................34
5.2. Roles and responsibilities of Regional/City administration/ Health bureau.........................................35
5.3. Roles and Responsibilities of ZHDs.......................................................................................................35
5.4. Roles and Responsibilities of Woreda Health Office.............................................................................35
5.5. Roles and responsibilities of health development partners.................................................................36

Annexes.....................................................................................................................................................36

Acronym

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 1. Introduction
The Ethiopian Federal Democratic Republic has ten Regional States and two City
Administrations with decentralized Zonal and Woreda structures. Woredas serve an estimated
100,000 people and are governed by an elected Woreda council. Woredas are further

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decentralized into Kebeles, which are the lowest administrative structures in Ethiopia.
Based on health system of the country, on average, Woredas have 20 health posts, 4 health
centers, and one primary hospital. One health center with its five health posts makes up the
Primary Health Care Unit (PHCU). Rural health centers serve from 15,000 to 25,000 people
whereas urban health centers serve up to 40,000 people. A health post serves from 3,000 to 5,000
people. Heath centers provide basic health service packages and are centers for referral and
practical training for health extension workers.

Primary hospitals serve an average of 60,0000 to 100,000 people and provide blood transfusion,
and minor and emergency surgeries, in addition to services typically provided at the health center
level. Primary hospitals serve as a referral center and practical training institution for
professionals working at PHCU level.

The Ministry of Health (MOH) has set ambitious goals in the second Health Sector Transformation Plan
(HSTP-II) for the next five-year national health sector strategic plan, which covers the period between
2013–2017 EFY (July 2020–June 2025) to improve the health status of the population by realizing four
objectives; which are accelerate progress towards universal health coverage, protect people from health
emergencies, Woreda transformation and improve health system responsiveness.

Thus, Woreda Transformation is one of the intermediate result/objectives of the HSTP II and aims to
create high performing Woredas that fulfill the vision of the health sector and meet the demands of the
community they serve. Model Woreda can be created through creating model households and kebeles
through meaningful community ownership and engagement, ensure a resilient Woreda health
management systems which is able to provide quality, sufficient and timely response to public health
emergencies; and creating high performing Primary Health Care facilities that provide quality and
equitable health services.

1.1. Situational analysis of Woreda Transformation

In the first Health Sector Transformation Plan (HSTP-I) period the Woreda Transformation has been one
of the four transformation agenda, which has been envisioned to serve as a vehicle to achieve
accessibility, quality, and equity in primary health care services; to increase community ownership, and

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to create a resilient Woreda health system. Furthermore, it is believed to be a pathway to achieve HSTP
goals and advance other transformation agendas forward. Thus, the aim of Woreda Transformation was
to create high performing Woredas that fulfill the vision of the health sector and meet the demands of
the community they serve. This agenda had four interrelated components including creating high
performing PHCUs, model Kebeles, and enrollment of the HHs in CBHI and implementation of Woreda
management standard.

Major initiatives and activities implemented

Some of the major initiatives done to realize the WT agenda during the HSTP-I includes; developing
implementation manual, providing massive capacity building trainings, series of sensitization sessions,
providing technical guidance to RHBs and the Woredas targeted for transformation, providing financial
support, facilitating experience sharing visits among Woredas. With regard of performance monitoring
conducting supportive supervisions visits and periodic performance review meetings, conducting regular
verifications and providing feedbacks based on their respective performance.

Some of the community level interventions were competency based trainings for WDAs,
implementation of community score cards, school health initiatives and an initiation of HEP
optimization. Different reform activities were implemented at the health facility level some of these
were an implementation of reforms (EPAQ, EPHCG, CASH…). At woreda level an implementation of
WMS were some of the major interventions implemented to achieve the broader Woreda
transformation agenda.

Major achievements
In the first transformation period it was planned that the implementation would have a phased
approach. It was anticipated that to roll out the Woreda transformation agenda in 100 Woredas in the
first two years and to be progressively scaled up to the rest of Woredas in the remaining 3 years.
The overall performance has been monitored using the performance-tracking dashboard created for this
specific purpose. At the end of the HSTP-I period (the fourth quarter of the EFY 2012), a total of 439
Woredas, have reported their performance status. Among these, only 49 Woredas were rated as model,
109 medium performing, 107 low performing and 174 categorized as very low performing. From the
reported 49 model Woredas, 21 were from SNNPR, 15 from Addis Ababa, 10 from Amhara, and 3 were

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from Oromia region. However the overall, implementation of the Woreda transformation agenda has
created a high momentum to improve the performance of the woreda/district health system. Outcome
level indicators identified to measure Woreda transformation are aligned with the UHC measurement
index and HSTP goal of health for all through primary health care. Regular monitoring and recognition
system of model woredas have also created a competitive environment among RHBs and woredas.

Looking at the components of Woreda transformation; the average Woreda management standard
score of the above mentioned 439 Woredas was 73%, from a total of 8,444 that reported their status
1,715 (20%) kebeles were rated as model and from a total of 1671 PHCUs reported their status 298
(18%) PHCUs were rated as model. Community based health insurance (CBHI) enrollment is another
component of the WT agenda. At the end of the transformation period a total of 827 woreda from five
regions and one city administration were covered by CBHI, out of these 743 (90%) woredas have started
providing service using the CBHI scheme.

During the later years of HSTP-I, the Woreda transformation agenda implementation has inspired the
concept of multi-sectoral Woreda transformation that envisions bringing about multi-sectoral district
transformation through improving Livelihood, Literacy, Longevity, and Lifestyle of people. In 2012EFY,
Gimbichu Woreda from East Shoa Zone of Oromia Regional State was selected as a pilot site for multi-
sectoral district transformation. Development of multi-sectorial implementation manual, a series of
consultations with different relevant sectors office and the selected Woreda leaders conducted,
Documented baseline status of the Woreda based on selected multi-sectoral indicators and
development of implementation strategy to this pilot site were among the major accomplishments of
the multi-sectoral Woreda transformation activities at Gimbichu Woreda.

Major challenges identified in the implementation of WT agenda in HSTP-I period

Due to the multifaceted challenges the implementation of Woreda transformation was far behind the
target set of the period. The major challenges in this regard includes, gap in integration with other
transformation agendas, unable to sustain the gains, , High discrepancy between the self-assessment and

verifications results, gaps in Linking measurement with improvement, weak sectoral and multi-sectoral

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collaborations and coordination, recent flagging of community engagement and health extension
program, high attrition and turnover of staff and leaderships, limited leadership capacity at Woreda
health offices, limited infrastructure at health facilities, shortage of budget, Some of the indicators have
no data source/difficult to measure, gaps in integration with DHIS2 and lack of efficient digitized
information systems.

1.2. The scope of Woreda Transformation in HSTP-II

The overall aim of Woreda transformation is to accelerate progress to achieve universal health coverage
through resilient primary health care system that effectively and efficiently responds to the need of the
peoples. This requires building implementation capacity of Woredas, having an accountable and
transparent governance system through nurturing meaningful community engagement and evidence
based decisions to identify bottlenecks and scale-up best practices.

The health sector, through its PHC approach, will consider the role of individuals, families and
communities in promoting health and wellbeing. Households are considered as the center of gravity to
address the challenges of families and tap potentials of the community for inclusive and sustainable
development. Therefore, transformed households highly contribute to the nation’s growth and
development efforts of ending poverty and hunger and promote health & wellbeing. Transforming
households in a given Woreda results in a transformed Woreda, where the environmental, social,
economic and other dimensions of development are improved. Such holistic development approach that
focuses on household impact will result in better health and well-being by addressing the social
determinants of health. Transforming Woredas require community participation, engagement,
empowerment and ownership. It also requires a multi-sectoral collaborative effort, another element of
PHC approach, to address development issues and social determinants of health. The health sector will
contribute towards a multi-sectoral Woreda transformation.

Woreda Transformation is one of the four objectives in HSTP-II and has a threefold meaning:
1. It is an aspiration to see a transformed Ethiopia at each Woreda. Woreda is a structural unit
which is better positioned for programmatically manageable and politically accountable
programming to implement socioeconomic strategies closer to the community mainly with
enhanced engagement of individuals and communities.

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 2. It is a pathway towards development by using households as building blocks of nations. Hence, it
promotes transforming all households from the level they are now to the next socially
acceptable level in a manner that does not slide back. This sets Ethiopia to prosper making all
forms of poverty to be part of history.
3. It is a means to cascade SDG to sub national level; so that no one is left behind by
tailoring/customizing national programs to local context and creating ample space for local
wisdom and ownership.

1.2.1. Multi-sectoral woreda transformation

The Performance measurement of Woreda transformation objective will be based on two dimensions:
Multi-Sectoral Woreda Transformation and sector-specific Woreda transformation. Multi-sectoral
woreda transformation will be measured using MSWT performance measurement indicators such as
Livelihood related indicators (food security, income level of households and other economic
measurements), Lifestyle indicators (Including household physical condition, household utilities (such as
water, latrine, energy…), use of technologies (access to information etc…), Literacy indicators (adult
literacy, girls’ education and other education indicators) and Life expectancy and related indicators
(Health impact indicators). Whereas the performance of Sector-specific Woreda Transformation: will be
measured according to the sector’s respective contribution towards multi-sectoral development.

1.2.2. Health Sector-specific Woreda Transformation:

The health sector, through its PHC approach, will consider the role of individuals, families and
communities in promoting health and wellbeing. Households are considered as the center of gravity to
address the challenges of families and tap potentials of the community for inclusive and sustainable
development. Therefore, transformed households highly contribute to the nation’s growth and
development efforts of ending poverty and hunger and promote health & wellbeing. Transforming
households in a given Woreda results in a transformed Woreda, where the environmental, social,
economic and other dimensions of development are improved. Such holistic development approach that
focuses on household impact will result in better health and well-being by addressing the social
determinants of health. Transforming Woredas require community participation, engagement,
empowerment and ownership. It also requires a multi-sectoral collaborative effort, another element of
PHC approach, to address development issues and social determinants of health.

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The health sector will work in close collaboration with relevant sectors and contribute towards holistic
MSWT. The health-sector specific Woreda transformation mainly focuses on strengthening and
transforming district health systems through improving key health system investments and
implementing high-impact health interventions mainly at household and primary health care levels. It
will focus on creating model households, model kebeles and high performing primary health units
(PHCUs) through a meaningful community engagement and a transformed Woreda leadership. It also
focuses on implementation of Woreda management standards, reforms and implementation of health-
financing strategies to reduce financial risks to the community.

1.3. Rationale
Woreda transformation is a pathway towards holistic development by using households as building
blocks of nations which helps to promote transforming all households in a manner that does not slide
back. In Ethiopian context, Woredas can serve as a means to cascade SDG to sub national level so that
no one is left behind by tailoring/customizing national programs to local context and creating ample
space for local wisdom and ownership.

Considering the Woreda as the most important political and administrative structure, which is
responsible for the delivery of health service; Woreda transformation agenda was designed and has
been implemented during the HSTP –I period. Through the implementation processes, lots of best
practices, challenges and lessons have been faced and documented. In the HSTP-II implementation
period, Woreda transformation is also identified as one of the four objectives; which is operationally
defined as high-level result statements. This indicates that woreda transformation can be the indicator
to measure the successful implementation of HSTP and make every effort to achieve this objective.

Therefore, from the past experience and lessons, there is a need for a clear framework to guide the
implementation of Woreda transformation interventions and also there is a need for robust tool to
measure its performance. So that, it is agreed that to revise the existing implementation guide and
measurement approach of woreda transformation building on the lessons gained during
implementation of HSTP-I and to be in-line with the framework of HSTP-II.

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 Section Two:

Woreda transformation implementation approach

in HSTP-II

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 2.1. Goals and Objectives of Woreda Transformation in HSTP-II

Goal: Accelerate progress to achieve UHC through resilient PHC system that effectively and
efficiently responds to the need of the peoples.

Objectives
 Create model households and kebeles through meaningful community participation,
engagement, empowerment and ownership.

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  Create high performing Primary Health Care facilities that provide quality and equitable
health services.
 Improve the capacity of the leadership at Woreda and PHCU level to enhance them to
provide quality, sufficient and timely response to public health emergencies; and to
create transparency and accountability.
 Ensure financial protection of people while accessing health services through health
insurance mechanisms such as CBHI
 Improve data use practice for evidence based decision making at Woreda and lower
levels
 Foster multi-sectoral collaboration and coordination towards a holistic development.

2.2.Definition of concepts
 Woreda transformation- is a pathway towards development by using households as building
blocks of nations. Hence, it promotes transforming all households from the level they are now to
the next socially acceptable level in a manner that does not slide back.
 Model Woreda- if a Woreda achieved ≥ 85% on the average Woreda Performance score, it can
be labeled as a model woreda only for the evaluation period.
 Transformed Woreda- If a model woreda has sustained as model a model woreda for at least
two consecutive years, it can be transformed Woreda.

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  Multi-sectral Woreda transformation- is a means to ensure inclusive growth, this focuses on
holistic development at the community level, which can be addressed by integrated multi
sectoral interventions.
 Health-sector specific Woreda transformation- is about strengthening and transforming district
health systems through improving key health system investments and implementing high-
impact health interventions mainly at household and primary health care levels through
effective community engagement and ownership.
 Model kebele in health-refers to having families in a kebele that have gone beyond achieving
model family status individually to creating a socially responsible, organized and sustainable
transformation of the health status of the community.
 Model Households-it is all about ensuring the HEP packages are well understood and
implemented by each households
 Transformation HHs - it is all about ensuring the HEP packages are well understood and
implemented by each household and sustained the gains at least for two consecutive years.
 High performing PHCU- is one that has a strong governing board, maintaining active community
participation, provides quality and equitable health services to all and keeps the community it
serves satisfied.
 Model School in Health- is a school with safe water, improved latrine with hand washing facility,
has dry and liquid waste disposal facility, has first aid kits for emergencies, regular screening and
has different health clubs.

2.3.Woreda Transformation towards Universal Health Coverage

The woreda transformation helps to accelerate the progress towards universal health coverage (UHC).
Woreda Transformation is overarching agenda or the outcome of the effective implementation of other
transformation agendas. Health services in a transformed Woreda are provided in an equitable and
quality manner with improved health service coverage, improved service utilization and better health
outcomes. To achieve this, it aspires to build excellence in the four key Pillars-Health information,
innovative financing, health workforce and leadership using the major strategies and interventions
outlined.

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A transformed woreda is expected to have a leadership with an accountable and transparent system
that creates an enabling environment to translate plans into results. It will have the vision and capacity
to transform households and community to timely respond to the needs of the people. It will make
evidence informed decisions based on the generation and use of quality data that is supported by health
technologies. Therefore, it works towards transforming a cultural and attitudinal changes of high-quality
data use to monitor the performance of health system in a woreda. Moreover, transformed Woredas
implements innovative health financing strategies that improve the capacity of health system and
reduces financial risks of the population. To provide quality of health service in equitable manner, the
health workforces that provide health services need to be competent, motivated and compassionate by
applying different strategies such as creating an enabling work environment with clear roles and
responsibilities, equitable remuneration packages, and performance support.

The above-mentioned areas are the priorities of HSTP-II in which the health sector plans to invest more.
However, based on contexts, there are areas when the timing and sequencing of interventions are very
important, and a region or woreda must consider ensuring that appropriate investments are made; such
as infrastructure, community, medicine, products and supplies.

Therefore, a transformed Woreda will have the following attributes which are directly related to key
health sector priorities or health sector transformation agendas and its achievement will be measured
by the outcomes of the priority areas listed below:
1. Creation of model Kebeles/Health posts through enhanced community participation and
engagement.
2. Creation of high performing primary health care units (PHCUs); which are able to provide
quality and equitable health services. Finally this could be measured by the performance of
all primary health care facilities.
3. Creation of model Woreda health offices; through transformed in leadership; improvements
in performance of Woreda Management standards and reforms and enhanced multi-
sectoral engagement of the health sector to the holistic development.

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 Figure 1: Framework of Woreda Transformation towards Universal Health Coverage

2.4. Investment/Intervention areas

The ministry of health has been providing focused and tailored support to regional health bureaus to
implement the woreda transformation agenda since the commencement of HSTP-I. In the
implementation processes, we have learned that the interventions were not well linked to the expected
outcomes and proper designing of improvement plans. Therefore, it’s important to consider the wider
health system approach such as health information, Human resources, community, logistics and supply,
infrastructure and others. However, the level of investments on each health system building blocks is
depending on the gaps identified through regular monitoring and evaluation systems. For this, a woreda
level analysis helps to determine the priorities and this in turn creates opportunities to identify needed
to produce required deliverables.
Therefore, the interventions must be determined based on a comprehensive assessment and gaps
identified. Based on the identified gaps and with clear theory change towards the expected results, a
potential list of options/intervention must be considered. However, depending on the resources
availability, need, effectiveness and other criteria of enabling factors, the intervention areas might be
prioritized. Some major interventions areas are identified in table __ below to just guide the
implementers or managers use them based on their priorities and available evidences.

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Table 1: Summary of Major Interventions/Investments
Thematic area Major Interventions/Investments
Implement revised Woreda Management Standard implementation in all woredas for
performance improvement
Implement community score card
Strengthen PH/HC/HEP governance board based on the guidelines
Implement and track good governance index at primary health care level facilities
Implement Managerial accountability system for PHC
Strengthen HEP leadership and governance
Merit-based assignment of Woreda managers
Private sector engagement for collaboration at PHC level
Leadership and Establish/revitalize functional technical coordination system for Transformation Agendas at
Governance woreda level
Improve partnership (map partners and activities, joint forum)
Multi-sectoral coordination (planning, oriented on WT, joint review meeting...)
Strengthen multi-sectoral steering committee at woreda and kebele level
Assign a focal person for each transformation agenda
Regulate Private and public health facilities
Establish, implement, and monitor EPAQ in all Woredas
Capacity building trainings such as District Health Management for Health managers,
Primary Health Care Management Development Program (PMDP) and Strategic
Management Development Program (SMDP)
Avail essential health services expected to be provided at the Primary Health care facilities
Ensure implementation of essential health services at all level of facilities including
comprehensive health post
Implement PHEM (preparedness, forecasting, management and response)
Quality and Quality Improvement process from primary hospital, health center, health post, and
equity health community
services at Implement HC to HP mentorship
Primary health Clinical audit and review at PH, HC, and HP
care facilities Implement mentorship between hospital and HC
Establish functional QI teams in HCs
Ensure availability of Water and power supply
Improve revised EHCRIG reporting system in all health centers
Implement HPRIG at health post
Regular equity analysis and improvement
Capacity building on clinical communication
Implement HEP optimization changes (restructure service delivery, services, HRH…)
Avail basic amenities for HPs
Proper ambulance management
Implementation EPHCG
Improve staffing pattern in the health facilities
Operationalize OR service in health centers where OR block is constructed
Health education materials and implement facility based health education
Training and full implementation of CASH-IPC
Provide training for the Health Professionals
Initiate community pharmacy and pharmaceutical audit

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 Strengthen pharmaceutical and supply chain system
Improve medical devices preventive maintenance, management of medical equipment,
train technicians and users, Monitoring and evaluations
Quality improvement trainings for Primary health care facilities staff
Conduct quarterly Quality Improvement coaching and mentoring support to the respective
HCs and health posts
Organize based learning collaborative sessions
Conduct regular measurement and continuous quality improvement
Develop tailored quality projects and implement at each Health Facilities
Effective referral (referral protocols, standards, service directory…)
Strengthen linkage between PH,HC, and HP
Capacity building for volunteer community health workers
Resource mobilization from the community including formalization of resource collection
via healthcare financing
Scale up implementation of alternative community engagement strategies (VHL, optimize
WDA, men and youth engagement, informal social structure…) for healthier families and
households
Implement motivation mechanisms for volunteer community health workers
Strengthen/revise implementation of CSC and representation health facility governance
Community
Implement contextualized SBCC interventions including digitized SBCC tools
Leverage kebele level administration for HEP
Improve implementation of revised school health program approach
Implement health post open house event
Revise and use model HH criteria
Team-based outreach services for mobile and hard to reach areas
Community-based rehabilitation to people with disabilities (health care, skill training, family
life…)
Community mobilization on CBHI and improve coverage of the membership
Initiate social insurance [for civil servants]
Initiate service provision in facilities where CBHI started
Start clinical auditing in health facilities
Providing training for facility heads, Auditors and woreda health office heads on HCF reform
Health Financing
components, public financial management system and negotiation skills for budget
allocation
Revenue retention and utilization for quality care
Introduce user fee at comprehensive health post
Advocacy about the health care financing strategy for respective political leaders
Health workforce Establish learning platforms to build capacity through peer learning, improve knowledge
/Motivated, and skills
competent and Deploy adequate number and professional mix of HRH at PHC facilities including
compassionate comprehensive HP
health workforce Multi-disciplinary team-based support and care for better quality of care
Create conducive working environment (housing, baby friendly working environment, CPD,
licensing for all professionals )
Implement retention and motivation mechanism to retain and improve performance of
staffs (career pathways, capacity building, transfer…)
Provide training on MCC
Enhance capacity of staffs through coaching, mentorship, and supportive supervision
Harnessing digital platforms for capacity building

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 Implement HRIS
Provide integrated refresher training for HP staffs
Construct, expansion, renovation, and maintenance of health facilities
Construct new HPs for comprehensive HPs
Infrastructure Avail basic amenities at HFs (water-through harvesting rain water, multi-sectoral approach,
electricity
Ensure implementation health facility standard
Medicines, Strengthen supply chain management system (storing,
supplies, and Update and implement standards, list of drugs and supplies
logistics Establish auditable pharmaceutical transactions and service
Deploy full staff per standard for M&E planning unit
Ensure availability of materials and logistics (computer, internet, tools, shelves…)
Provide need –based training on health information systems
Conduct RDQA per the standard
Provide training on data quality, use, management, DHIS-2 Implementation, CHIS
Implementation, eCHIS Implementation
Information
Full implementation of eCHIS
Revolution
Routine monitoring of the functionality of LAN and HealthNet
Onsite coaching/reminder for documenting reporting completeness and timeliness status
Revitalize the PMT according to the standard
Establish/strengthen team level performance review meetings
Onsite training /Mentorship to the PMT members (Problem-solving skill, 5-step data use
cycle)

3. Performance Management for Woreda Transformation

Performance management is a systematic process by which an organization involves its employees in
improving the effectiveness of the organization and achieving the organization’s mission and strategic
goals. In the performance management cycle of the health system the role of the leadership is
fundamental in establishing a system for accountability and transparency, in providing customer focus,
creating strategic alignment and enhancing a culture of quality in health care. By improving performance
and quality, the health systems can save lives, cut costs, and get better results and it enables the health
system to be more efficient, effective, transparent and accountable. Hence, Performance standards,
Performance measurement, Quality Improvement, Reporting Progress and Strong leadership are the
major components of performance management for the Woreda transformation.

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 Performance Management System Framework for Woreda transformation

Performance standards
In the HSTP-I period model Kebeles, creating high performing PHCU, enrolling HHs in CBHI scheme, and
performance of Woreda management standards were used as a criteria to measure the performance of
a Woreda. In considering the lessons gained from the previous experience aggregated indicators for
leadership and governance, health financing, MCC; health workforce, Information Revolution (IR) and
the score key performance indicators (KPIs) for quality and equity were selected to measure the
performances of Woreda management in the second HSTP period. Therefore, the goals and targets for
each the selected indicators for Woreda transformation must be aligned with above-mentioned criteria.
The targets for each indicator/criteria may be different at different levels (MOH, RHB, ZHD, Woreda,
facilities and community). However, all stakeholders should work towards achieving the targets of
Woreda transformation which is 85% and above.

Performance measurement
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An effective performance measurement is the backbone for a successful implementation of Woreda
Transformation. To have a successful performance management defining indicators, robust data
collection and management system is very important. The following key performance measurement
components will be given a focus for Woreda Transformation;
 Selecting and defining indicators to measure the achievement towards Woreda transformation.
 Identify data sets/elements to be extracted from a well established health management
information system (DHIS-2)
 Separate data collection tool will be developed for few data elements which can’t obtain from
DHIS-2.
 Revise and implement performance tracking tool/s and integrate with the existing health
information system
 Conduct regular supportive supervisions, mentorship programs has to be provided to the lower
level.
 Regular performance monitoring, feedback and tailored support will be provided
 All data source will be collected and documented at each level and make sure data sources are
easily available.
 Baseline assessment will be done and the progress will be monitored through Quarterly self-
assessment.
 Woreda transformation self-assessment report with DHIS-2 data source and other
administrative reports will be triangulated to ensure reliability & accuracy of the data.
 Validation and Verification of the performance of model Woredas on regular bases.

Quality improvement
Quality improvement is a continuous process whereby organizations iteratively test and measure
changes in work routines, set and achieve ambitious aims, shift whole system performance, and spread
best practices for rapid uptake at a larger scale to address a specific issue or suite of issues they have
determined to improve.

Quality improvement in the Woreda transformation will begins with an identification of a clear aim
statement, to answer the question: “What are we trying to accomplish?” For this mater Kaizen and
Model for improvement; which are complementary each other, will be implemented to accelerate the

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performance of Woreda transformation. Kaizen is thought of as the engine driving improvement, while
the Model for Improvement can be seen as the “vehicle” that provides structure for improvement.
Specifically, Kaizen focuses on improving efficiency and lowering cost, through a methodology that can
be integrated with other complementary quality improvement tools and approaches, such as the Model
for Improvement. Hence all Woredas and health facilities are expected to apply their lessons and
experiences of Kaizen and model for improvement to accelerate the progress towards Woreda
transformation and then universal health coverage. The main focus of quality improvement process in
Woreda transformation is to accelerate the progress by improving the use of data for decisions decision
making.

Reporting the progress

Developing progress report and submitting to the upper level is critical in performance management. So
that Woredas are expected to collect, analyze and interpret data from the lower level regularly and
expected to conduct internal self assessments based on the pre-defined performance indicators and
expected to take corrective measures. Zonal Health Departments and Regional Health Bureaus should
identify high, medium and low performing Woredas and customize their support to maintain
performance of high performing Woredas, transform medium performing Woredas to high
performance, and provide intensive support to low performing Woredas to address their challenges and
transfer lessons from high performing Woredas.

Strong leadership
As mentioned above implementation capacity of the leadership is very crucial. Leadership commitment,
in this regard, characterized by fostering a culture of quality that aligns performance management
practices with the organizational mission, regularly takes into account customer feedback, and enables
transparency about performance against targets between leadership and staff. To improve the support
and engagement of leadership including political leadership, the following major activities should be
undertaken:
 Orientation and advocacy to leaders at all levels
 Engage leadership in performance management processes
 Align performance management with government priorities
 Track and incentivize progress

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 3.1. Performance Review Mechanisms (PRM)
Generally, performance review is a critical component of overall performance management strategy
which focus on evaluating past performance. And also it should be conducted periodically and should
focus on driving and improving future performance. At each level PRM is expected to share lessons
among better performing Woredas and to take corrective measures to improve identified gaps.

Each components of the Woreda transformation should be considered while identifying major gaps and
reviewing them. Beside identification of the critical gaps in the process of implementation, setting action
plan with all relevant bodies which are accountable for the improvement of identified gaps with
specified time to accomplish the task is very crucial.

It is recommended to conduct review meeting at least bi-annually at national and regional level, paired
with a year-end review of general components, notes, progress, and next steps. This allows all relevant
stakeholders, experts, coordinators and leaders to stay on the same page about goals, progress, and
performance. However, at Woreda and facility level it can be done quarterly or on monthly basis. It can
also be integrated with the PRM activities with the existing teams to review routine data and reports.

3.2. Performance measurement indicators

The following tables show the list of key performance measurement indicators to monitor the progress
of health facilities/institutions towards high performing entity.
A. Indicators for Model Health Posts/Kebeles
Transformation Indicator
S/No # Indicator
Agendas (TAs) weight
1 Proportion of model households 20%
2 Proportion of HHs with access to improved latrine 5%
Quality and
3 Dropout rate (Penta 1 to MCV1) 5%
1 Equity Score
(40%) 4 HP Outpatient attendance per capita 5%
5 Availability of essential Drugs for 5%
Total Quality and Equity Score (KPIs) 50%
1 Reporting timeliness 6%
Proportion of conducted LQASs from the expected in the
Information 2 6%
period
2 Revolution Updated minimum display charts (EPI, Malaria, performance
Score (20%) 3 8%
monitoring chart)
Total Information Revolution Score 20%
1 HP Reform implementation score 16%
Leadership/ 2 Functionality of WDA 7%
3 Governance 3 Model school status 7%
Score (40%) 4 Membership enrollment rate for CBHI
Total Leadership/Governance Score 30%
Total for Model Health Post/Kebele 100%

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 B. Indicators for High performing PHCU/Primary Hospital
Transformation Indicator
# Indicator
Agendas Weight
1 Contraceptive acceptance rate (CAR) 1.5%
2 Proportion of pregnant women that started ANC early (less than 16 weeks) 1.5%
3 ANC 4 Coverage 1.5%
4 Skilled Delivery Coverage 1.5%
5 Early PNC Coverage 1.5%
6 Drop-out rate from ANC1 to Delivery 1.5%
7 Proportion of Pregnant, Laboring and lactating Mothers tested for HIV (PMTCT) 1.5%
8 Proportion of Pregnant Mothers screened for Sphylis 1.5%
9 Fully immunization coverage for under one year children 1.5%
10 Dropout rate (Penta 1 to MCV1) 1.5%
11 Proportion of Pregnant Mothers supplemented with iron 90+ 1.5%
12 Vit A supplementation 1.5%
13 Proportion of children < 2yrs participated in GMP 1.5%
14 Cure rate of under five Children admitted for SAM 1.5%
15 HIV test positivity rate 1.5%
16 ART retention rate 1.5%
Quality and
Percentage of ART clients with a suppressed viral load (<1000 copies/ml)
Equity 17 1.5%
among those with a viral load test in the reporting period
Score (50%)
Percentage of HIV-positive pregnant women who received ART to reduce the
18 1.5%
risk of Women-to child-transmission (MTCT) during pregnancy, L&D and PNC
19 TB case detection contributed by community 1.5%
20 Tuberculosis treatment coverage
21 Tuberculosis treatment success rate 1.5%
22 Malaria cases per 1000 population at risk 1.5%
23 Proportion of women aged 30-49 screened for cervical Ca 1.5%
24 Proportion of adults screened for HPN 1.5%
25 Proportion of adults screened for DM 1.5%
26 Proportion of mental health screened
27 OPD Attendance per capita 1.5%
28 Patient satisfaction score 1.5%
29 Essential Drug Availability 1.5%
30 EPHCG implementation score 1.5%
31 PHCG audit score 2%
32 Average HP/Kebele quality and equity KPI score 6.0%
1 IR-HIS capacity and Infrastructure score 3.0%
Information
2 IR-Data quality score 3.0%
Revolution
3 IR-Data use score 3.0%
Score (15%)
4 Average HP/Kebele Information Revolution score 6.0%
MCC; Health 1 Staff satisfaction rate 5.0%
workforce
2 Provider competency level 5.0%
Score (10%)
Leadership/ 1 EHCRIG implementation score 5.0%
Governance 2 Community score card score 5.0%
Score (20%) 3 Average HP/Kebele leadership/governance score 10.0%
Health Financing
1 Share of internal revenue generated of total health budget 5.0%
Score (5%)
Total score for High performing PHCU/Primary Hospital 100.0%

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 C. Measurement Indicators for Model woreda
Transformation Indicator
S/No # Indicator
Agendas Weight
1 OPD attendance per capita 5%
2 Ratio of “Coverage of currently on ART” between pediatrics (<15)
Quality and 5%
and adults (>15)
1 Equity of care
3 Penta 3 coverage by geography (PHCUs) 5%
(20%)
4 Average PHCU quality and equity (KPIs) score 5%
Total Quality and Equity of care (KPIs) 20%
1 IR-HIS capacity and Infrastructure score 3%
Information 2 IR-Data quality score 3%
2 Revolution 3 IR-Data use score 3%
Score (15%) 4 Average PHCU Information Revolution score 6%
Total Information Revolution score 15%
1 Staff satisfaction rate 2%
2 Attrition rate 2%
MCC; Health 3 Health workers density (physician, nurses, midwives, HOs) per 1000
2%
3 workforce population
Score (10%) 4 Provider competency level?? --%
5 Average PHCUs MCC; Health workforce score 4%
Total MCC; Health workforce Score 10%
1 WoHO management standard Score 20%
2 Enhanced multi-sectoral engagement score 4%
3 Health center efficiency- Number of deliveries per month per HCs 3%
Leadership/
4 Coordination for integrated implementation of transformation
4 Governance 3%
agendas-availability of focal person
Score (50%)
5 Availability of essential Drugs for HP 5%
6 Average PHCU Leadership/Governance score 15%
Total Leadership/Governance Score 50%
1 Proportion of households enrolled in CBHI 2%
2 Proportion of fee-waivered
Health 3 Budget allocation (Share of health budget from the total
1%
5 Financing government budget)
Score (5%) 4 Budget utilization rate 1%
5 Average PHCU health financing score 1%
Total Health financing Score 5%
Total 100%

Criteria for Model Household

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HEWs expected to visit all of the households under the catchment and a household will be labeled as a
model household if and only if it fulfills all of the criteria listed below.
SN Model Household criteria Remark
1 Infants immunized with all antigens they are eligible for
2 Children aged 6-59 months received vitamin A supplementation in the house
3 GMP conducted for under 2 children in the house
4 Eligible women in the household using family planning
5 Pregnant women in the household attending ANC
6 A women with an infant has delivered in the facility
7 A women with newborn/infant has attended PNC
8 A women with newborn/infant exclusively breastfed/breastfeeding
9 A household in malarious areas with bed-net using the bed net regularly
10 Household participating in environmental management for control of malaria
11 Household in malarious areas voluntarily got their houses sprayed with
insecticides
12 Household have and using improved latrine
13 Household have liquid and solid waste disposal system
14 Household have smokeless stove/separate kitchen
15 Household have separate room for domestic animals
16 A household is a member of the community based health insurance (CBHI)
Total score

3.3. Verification processes and Criteria

In addition to self-assessment, continuous Zonal, Regional and National level verification to the lower
level has to be conducted periodically, which helps to ensure the quality of the implementation, identify
challenges and document best practices. The main aim of the verification exercise is to identify and
document implementation progress, challenges and best practices to transfer lessons from high
performing Woredas to medium and lower performing Woredas and to recognize the model Woredas.

3.3.1. Verification processes

Generally the following steps will be followed to identify the model/best performing Woredas.
Step 1: All Woredas with their respective health facilities will conduct the self-assessment in quarterly
basis using the WT tracking dashboard and send the report to the higher level within one month
following the end of the quarter.

Step 2: Zonal Health departments (ZHDs) will conduct verification for all model Woredas (at least
50%HC, one HP and three HHs from each HC will be covered) by self assessment bi-annually, and send

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the list of verified model Woredas to RHB for regional level verification within two month following the
end of the half year. (At least 50%HC, one HP and three HHs from each HC will be covered)

Step 3: Regional Health Bureaus (RHBs) will conduct verification for all Woredas categorized as model by
ZHD verification bi-annually and send the list of verified model Woredas to MOH for national level
verification within three months following the end of the half year. (At least 50%HC, one HP and three
HHs from each HC will be covered)
Step 4: Ministry of health (MOH) will conduct the verification for all Woredas which are categorized as
model by ZHD verification annually, and recognize the Woredas at ARM every year. (At least 50%HC, one
HP and three HHs from each HC will be covered)

Health Post/Kebele Level Verification

PHCUs are expected to verify all HP/Kebeles under their catchment based on the self-assessment report
from Kebeles. However, Woredas can take sample of model HP/Kebeles from each PHCUs if there are
shortages to cover the entire model HP/Kebeles.
In order to verify performance of HP/Kebeles, the MOH team should select one better performing
HP/Kebele under the selected PHCU randomly. The verification could be done in two ways.
1. The performance of the HP will be reviewed and verified according to the indicators selected for
the performance measurement.
2. For house hold verification, ask the HEWs to give you the family folders of 30 households, and
randomly select three households and visit the households using the model household criteria
checklist to determine the model household status of the selected households.
Collect the value of the criteria (yes/no) and determine if the household fulfills all the criteria (Model
household) or not and enter the number of model household from the verification (0-3). There is a
possibility that none, one or more of the household could be found model.

Instruction: Please fill yes (1) if the household is eligible for and fulfills the criterion or if the household is
not eligible for the criterion. Fill no (0) if the household is eligible for the criterion and doesn’t fulfill the
criterion. Example: If you are visiting a household where there is one lady who is pregnant, the
household will be evaluated for those criteria related to pregnancy and will be given values 0 or 1
depending on whether the household fulfills the criteria or not. But, as there is no woman eligible for

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 family planning in the household, the household will get values of 1 for the family planning criterion
automatically.

Model PHCU verification:

Woredas should verify all model PHCUs under their catchment. However, ZHDs, RHBs and MOH should
verify sample model PHCUs based on the report. The MOH verification team will randomly select 50% of
better performing PHCU from those PHCUs found in the woreda. Please communicate the
curative/PHCU Support team/ Woreda Transformation focal person or head of the woreda health office
in order to randomly select one of the better performing PHCUs. You may ask some three better
performing PHCUs and select one of them randomly.
Model Woreda verification:
Zonal Health departments (ZHDs) should verify all model woredas bi-annually; however, RHBs and MOH
should verify sample model woredas based on the report of ZHDs. Whereas ZHDs has to cover at least
50% HC, one HP and three HHs from each HC bi-annually, and send the list of verified model Woredas to
RHB for regional level verification within two month following the end of the half year.

3.3.2. Verification Criteria

The following indicators are selected to measure progress of Kebeles/HPs, PHCUs and Woredas towards
being model. The categorization of the level of progress they have made is measured using the following
intervals indicated in the table below.
Table: Verification Criteria for Model kebele/HP, High performing PHCU/HP and Model woreda
Criteria for Indicators Weight Low Medium Model Remarks
Quality and equity score 35 <70% 70-85% >85% Kebele will be
Model Health Information Revolution score 20 <70% 70-85% >85% considered model if it
posts/Kebele Leadership/Governance score 45 <70% 70-85% >85% scored an average
Average Performance score 100 <70% 70-85% >85% weight of more >85%.
High Indicators Weight Low Medium Model
Performing Quality and equity score 50 <70% 70-85% >85% A PHCU will be
PHCU/Primary considered High
IR implementation score 15 >85%
Hospital <70% 70-85% performing if it scored
an average weight of
HR/MCC implementation score 10 >85%
<70% 70-85% more >85%. All the
criteria need not to be
Leadership/Governance score >85%
20 <70% 70-85% fulfilled independently.
HCF implementation score >85%
5 <70% 70-85%

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 Average Performance score 100 <70% >85%
70-85%
Indicators Weight Low Medium Model
Quality and equity score 20 <70% 70-85% >85%
IR implementation score 15 <70% 70-85% >85%
In measuring a woreda,
Model Woreda HR/MCC implementation score 10 <70% 70-85% >85%
the performance of PHs
Leadership/Governance score <70% 70-85% >85% will be considered where
50
there is a hospital in a
HCF implementation score <70% 70-85% >85% Woreda.
5
Average Performance score 100 <70% 70-85% >85%
A Woredas will be categorized as indicated on the table above. A Woreda can be labeled as a model only
for the evaluation period if achieved ≥ 85% on the average Woreda Performance score. A Woreda can
be designated as transformed woreda: If it has sustained as a model Woreda for at least two
consecutive years. All the existing model and transformed Woredas will be verified every year together
with the newly reported Woreda.

3.4. Recognition mechanisms

Ministry of Health will be clear motivation and recognition system for model/high performing facilities
for their better performance and to create positive competition among woredas. The recognition will be
held annually during Annual Review Meeting (ARM) of the ministry. Pre-determined checklist or
verification checklist will be used to validate the report and status of the facilities. Multidisciplinary team
from different directorates of the Ministry of Health and implementing partners will be deployed to
conduct the validation process.
In addition to official recognition and certification of the model performing facilities, other financial or
non-financial reward will be provided to them. The overall process and result will be evaluated and
approved by the management team of MOH.

4. Implementation Arrangement
The following arrangements will be carried out to facilitate the implementation of the Woreda
transformation in health;
4.1.Preparation of measurement tools
 Update measurement tools and test (make it user friendly)
- Update the Woreda Transformation tracking tool based on WT measurement criteria.
- Customize the tool to track performance at HP, HC, and Woreda levels.
- Test the tool at various levels and make sure that it is easily understandable and generates
the performance results of WT in health.
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 - Incorporate the measurement tool into DHIS2.
- Give orientation for key actors and HMIS focal persons on how to use the tool/data entry,
extraction of performance data from DHIS2, analysis, and interpretation/.
 Finalize revision of key reform guidelines (for HP/ HCs/PHs).
 Revise the Woreda Management Standard based on the roles of the Woreda health office and
the framework proposed in this manual.
 Revise and update checklists used for measurement of performance, supportive supervision,
and verification.
 Standardize criteria used for model HH, Model school, and improved latrine.
4.2.Strengthen/revitalize coordination platform
Revitalization of Steering Committee
The achievement of holistic development at the community/household level requires integrated multi-
sectoral interventions. Woreda transformation steering committee will be revitalized to facilitate multi-
sectoral collaborative efforts and to address the development issues as well as social determinants of
health.
o Identification of Key stakeholders and establishment of Woreda transformation steering
committee that leads and coordinates the Woreda transformation activities.
o The steering committee has to be chaired by political leadership (chief administrator/vice
administrator at Woreda and zonal levels; vice president/Vice PM at regional and federal
levels) and comprises heads of key sectors (eg. Health, Education, Water, Women, and
Children Affairs, Agriculture, Finance, Public service…) health development partners/NGOs
and representative from private sectors.
o Prepare a joint plan that indicates the targets, role of each sector, timetable, resources
required, and monitoring and evaluation system.
o Approve the plan by Cabinet at each level.
o Prepare MOU and get signed by all member sectors and stakeholders of the steering
committee.
o Include “enhancement of multi-sectoral engagement” into Woreda transformation
measurement criteria to draw the attention of top leadership.
o Review the performance status of WT by steering committee regularly (monthly, quarterly,
bi-annually, and annually), identify gaps, provide feedback, and prepare an action plan for
improvement.

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Strengthen Health center and primary hospital boards to regularly evaluate Woreda transformation
performance as a priority agenda during EPAQ meetings and share experiences and best practices
among PHCUs and Woreda health Offices.

Establishment of Coordination committee within the health sector

It was emphasized in the HSTP II document that the implementation of key initiatives and agendas need
strong harmony, alignment, and mainstreaming across all program activities. Therefore, the
coordination of the integration of transformation agendas at all levels is crucial to realize the
achievement of the five transformation agendas of HSTP-II. The following activities will be executed to
ensure strong coordination.
 Update the guideline for interdepartmental integration of transformation agendas within the
health sector to guide the effective integration of activities and implement an integrated M&E
system at all levels of the health system.
 Clearly describe the objective, activities to integrate, roles and responsibilities, and M&E
system in the integration guideline so that it will be used as a standard guide for managers
and implementers at all levels during the implementation of the integrated activities.
 Establish the coordination committee that comprises directors from directorates/departments
implementing the transformation agendas of HSTP II (quality and equity; information
revolution; motivated, competent & compassionate health workforce; health financing; and
leadership).
 The coordination committee will involve directors from HEP & PHC, Medical Services,
Maternal & Child Health, Disease Prevention, Planning, Human Resource, Medical supplies,
Insurance Agency, EPHI, relevant implementing partners and donors, and chaired by the state
minister at FMOH and RHB deputy head at the regional level. At the zonal and Woreda level,
the ZHD head and Woreda health office head will chair the interdepartmental coordination
activities.
 Areas of integration for transformation agendas will include Advocacy and Sensitization,
Transformation agenda training, integrated supportive supervision (ISS), mentoring, review
meetings, learning visits along with review meetings etc.

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  The implementation of the integration activities of the transformation agendas will be
monitored regularly (monthly at Woreda and zonal level; quarterly at regional and federal
level) using indicators that are based on the integration activities.

Strengthening Woreda Transformation Technical Working Group

 Transformation agenda-specific advisory groups and technical working groups will be
established to support the governance and monitoring activities of HSTP II at each level.
 Woreda transformation TWG will be established at all levels and encompasses technical
experts from relevant directorates such as HEP and PHC, Medical Services, Maternal & Child
Health, Disease Prevention, Planning, Human Resource, Medical supplies, Insurance Agency,
PHEM, and development partners.
 Woreda transformation TWG mainly has the following roles and responsibilities.
o Provide technical advice and support to coordination committee and lower level
technical committees.
o Identify activities that need integration and collective action at each level.
o Ensuring effective dissemination and use of standards and tools.
o Identify and engage development partners working in the technical areas of Woreda
transformation.
o Mobilize and pool resources from different partners that work on Woreda
transformation initiatives and ensure its efficient utilization.
o Identify knowledge and skill gaps and provide need based capacity building trainings,
onsite mentoring and coaching.
o Facilitate and technically support the verification and integrated supportive supervision
activities.
o Identify performance bottlenecks, propose appropriate solutions, and support the
improvement interventions.
o Document best practices and support the scaling up interventions.
o Regularly monitor and review the performance using key indicators and measurements.
o Share performance results and feedbacks to coordination committee and make sure
that Woreda transformation is kept high on the top political agenda/management
committee agenda.

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  The TWG will be chaired by the HEP and PHC directorate/DPHP directorate.
 The TWG will meet monthly/quarterly to review the WT performance. In the process, they
review the performance, identify and analyze gaps, and design strategies.
 TWG will develop terms of reference including purpose, objectives, membership, roles and
responsibilities, and M&E system.

4.3.Conduct sensitization and advocacy on Woreda Transformation

 Preparation of sensitization/advocacy guide that gives directions on how to conduct
sensitization and advocacy activities at all levels.
 Advocacy and sanitization on Woreda transformation will be conducted through different
forums, panel discussions, and conferences.
 Conduct advocacy sessions including top leaders, steering committee members, and other key
stakeholders.
 Community orientation/sensitization will be conducted at lower levels including kebele
leaders, WDA leaders, religious leaders, CBO leaders, Youth leaders…) and focus on model
kebele and model HHs.
 Prepare and disseminate key information on Woreda transformation through Social media,
Websites, TV, Local Radios, and Other Media.

4.4.Conduct Training
 Develop a training guide that indicates the type of training, objectives, organizers, training
period, participants, and training topics.
 The training will be given in an integrated way and will help participants to get a holistic
knowledge on how to integrate HSTP agendas, objectives, implementation strategies, and
monitoring and evaluation mechanisms at all levels in general and on Woreda transformation
(revised manual, WT implementation process, measurement criteria, verification process, and
QI/change ideas) in particular.
 The training will be cascaded to Woreda and PHCU level and onsite orientation/training to
staff will be given by those experts who took basic training.

4.5.Planning and implementation

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  Assess the current implementation status and results of Woreda transformation, major
challenges and lessons learned at every level which serves as baseline data.
 Set clear targets on the intended results (creation of model households and model kebeles,
Creation of high-performing primary health care units, creation of model Woreda, CBHI, WMs,
Community engagement, and multi-sectoral engagement).
 Ensure that all levels (PHCUs, Woreda, zone, and regions) have Woreda transformation in
health plan which is approved by top leadership (Cabinet).
 Make sure that the plan and targets set at each level are interdependent and coincide (for
example, health posts and kebeles plan with health center plan; health centers plan with
Woreda plan, and Woredas plan with zone plan).
 Mobilize a community and relevant stakeholders at least once a year at Woreda level and bi-
annually at kebele level.
 Implementation of the planned activities.

4.6.Strengthen documentation
Source documents on the performance of Woreda transformation are usually lacking or incomplete and
major improvements are still needed in the documentation of plans, reports, follow-up activities,
minutes, feedbacks, and any related evidence at PHCU and Woreda level.
 Update standard checklists, indicators, performance summary sheets, guidelines, TORs, and
other related documents and share them to all levels to support the proper documentation of
essential data.
 Provide orientation on updated tools used for data collection, reporting, and documentation.
 Support and strengthen the capacity of PHCUs and Woreda health offices to use DHIS2 for
performance data reporting and data sources.
 Approve performance data by performance review team/PRTbefore entry to DHIS2 or being
reported to the next level.
 Follow-up and provision of feedback on timely reporting, proper documentation, and use of
data for informed decisions and performance improvement.
4.7. Monitoring and Evaluation

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  Create clarity on Woreda transformation indicators, targets, criteria, measurement
techniques, reporting system and schedule, and evaluation system for leaders/management
bodies, experts, and relevant stakeholders at all levels.
 Regular, participatory performance review meetings will be undertaken every month at PHCU
and Woreda levels and every two months, quarterly, biannually, and annually at zonal,
regional, and federal levels.
 Regular follow-up and support from a higher level to the next lower level will be carried out
through integrated supportive supervision that includes experts from transformation agendas
and objectives.
 Following reviews and supportive supervision, constructive and timely feedback will be
provided to the concerned bodies.
 Verification of model and transformed HHs, Kebeles, PHCUs, and Woredas will be conducted
quarterly by the Woreda health office and zone health departments; bi-annually by RHBs and
FMOH, and recognition will be given based on performance ranking.

5. Roles and responsibilities of different stakeholders

The implementation of woreda transformation is led by woreda transformation steering committee
established at different level from Ministry of Health to Woreda Health office. The committee oversees
the report received from the bottom level, by evaluating the achievement against the plan and provides
feedbacks on quarterly basis. Besides the committee will be expected to provide timely supportive
supervision based on performance.

5.1. Roles and responsibilities of FMOH

At federal level steering committee led by state minister for programs. The MOH is expected to perform
the following roles;
 Facilitate the preparation of woreda transformation implementation plan, manuals and other
supportive tools with respective directorate/team and partners, evaluate the plan and finally
approves.
 Identify the roles of different stakeholders/directorates, teams/ and partners have in common
and/or separately, develop performance measures for each activity.
 Providing continuous monitoring, evaluation and support.

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  Establish technical team who follows woreda transformation implementation status on monthly
basis.
 Receive report and review the implementation status of each region/city administration/ and
provide them feedbacks quarterly.
 Report the woreda transformation implementation status of regions to joint steering
committee/JSC/ meeting every two monthly.
 Organize national level review meetings
 Cross checks woreda transformation is the main agenda for political leaders at different levels
 Provides capacity building trainings compiles and disseminates best experiences.
 Reviews and amends the plan and other woreda transformation documents.

5.2. Roles and responsibilities of Regional/City administration/ Health bureau

Woreda transformation steering committee led by regional health bureau head/represented by him will
be established and the RHB will have the following responsibilities.
 Co-ordinates stakeholders (governmental and partners) to identify their role and to develop
memorandum of understanding/MOU/.
 Establish technical team who follows woreda transformation implementation status on monthly
basis and reports the finding to the next level.
 Timely follow up, supports and provide feedbacks for the zones based on their performance.
 Cross checks woreda transformation is the main agenda for political leaders at different levels.
 Continuously monitor and evaluate the performance of the woreda, identify the gap and
provide capacity building to fill the identified gaps.

5.3. Roles and Responsibilities of ZHDs

At Zonal/special woreda/sub-city/level Woreda transformation streaming committee led by zonal health
office head will be established and will have the following responsibilities.
 Co-ordinates stakeholders (governmental and partners) to identify their role and to develop
memorandum of understanding/MOU/.
 Establish technical team who follows woreda transformation implementation status on bi-
monthly basis and reports the finding to the next level.
 Co-ordinates the performance of streaming committee on monthly basis.

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  Based on the achievement of the woreda management standard (WMS) support, monitor,
evaluate and give recognition for woredas annually.
 Cross checks woreda transformation is the main agenda for political leaders at different levels.

5.4. Roles and Responsibilities of Woreda Health Office

Establish Woreda transformation streaming committee led by woreda head and have the following roles
and responsibilities;
 Develop woreda transformation implementation plan and submit for woreda cabinet for final
approval.
 Identify the roles of stake holders/ sectors/ in the woreda; education office, woreda water
office, Woreda women, children and youth office, woreda women league, Woreda sport office
and other partners in woreda transformation implementation, sign MOU on the agreed plan
implementation and to evaluate the progress monthly.
 Establish technical team (Woreda health office deputy head, Woreda health office HEP and
hygiene officer, woreda health office CBHI coordinator and woreda administration office) who
follows woreda transformation implementation status on weekly basis and reports the finding
to the next level.
 Facilitates to sign MOU among stakeholders before implementation of approved woreda
transformation implementation plan by incorporating accountability and responsibility
 Woreda health offices perform self-assessment based on woreda management standard and
provide continuous support to improve performance.
 Take weekly report from primary health care unit, review the report and give feed backs.
 Based on gap identified by field supportive supervision and review meeting provide capacity
building trainings for HEW and other PHCU staffs.

5.5. Roles and responsibilities of health development partners

Non-state actors (NGOs and others) are expected to perform the following activities;
o Participating in the streaming committee established at different levels and provides their
expertise support for the committee
o Participating in supportive supervision conducted at different levels.
o Aligning their annual plan with the sectors’ plan.

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 o Based on the initial woreda implementation plan provide capacity building from top to bottom
across the sector.

Annexes
 Indicators definition will be annexed

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