Developing and validating a multi-dimensional instrument for measuring the performance of district health systems in a national region in Ethiopia

Background: Despite being the main vehicles of primary healthcare provision in Ethiopia, district health systems lack comprehensive set of valid performance indicators that are both process and outcome oriented. Therefore, we aimed to develop and validate a set of performance indicators for district health systems of Oromia Region, Ethiopia. Methods: We used a sequential mixed-methods design. During development stage, we employed a qualitative interview study in Oromia Region, Ethiopia. We transcribed, did in vivo coding and inductive analysis of the interviews. Moreover, we conducted a narrative systematic review. Records on performance of health systems were appraised and synthesized. Then, during the validation stage, we supplied the indicators generated from the previous two studies to experts in the field of health systems as part of a Delphi study. In the Delphi study, experts voted on the inclusion- or exclusion-of indicators in three stages. Results: Eleven functions of district health systems emerged from the interviews including: creating capacity of health centers for the provision of health care; and provision of comprehensive health care for communicable diseases and maternal health conditions, among others. Furthermore, 59 out of 238 indicators generated by the interviews and the systematic review were found to be valid by experts. Among these, 40 were found to be able to be drawn from the information systems in the districts. The indicators addressed multiple dimensions of performance of district health systems, such as capacity, quality, and outcomes. Among valid and feasible indicators were rate of utilization of family planning methods, and tuberculosis cases per 1000 people. Conclusion: Policy makers can use the valid indicators to monitor national policy priority areas like the expansion of family planning services. Moreover, the indicators can be used in the districts for local decision making, for example, to identify poorly performing functions and take corrective action.