Published in PLOS One on 2026-07-23, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Biruk Bogale, Gizachew Tadele Tiruneh, Mesele Damte Argaw, Agumasie Semahegn, Nebreed Fesseha, Chala Tesfaye, Mikiyas Teferi, Hillina Tadesse, Mebrie Belete, Addis Girma, Temesgen Ayehu, Yibeltal Siraneh, Yibeltal Kifle, Bezawit Mesfin Hunegnaw, Dessalew Emaway
Source: PLOS One • DOI 10.1371/journal.pone.0353519
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Optimizing Ethiopia’s Health Extension Program (HEP) has been critical to enhancing primary healthcare (PHC) service delivery, particularly in remote and underserved settings. Embedded implementation research (EIR) strengthens PHC systems by positioning implementers and local managers at the center of addressing operational bottlenecks, enabling adaptive, context-specific refinement of interventions and strategies while maintaining high fidelity to their core components. This study evaluates the implementation fidelity, adaptation of strategies, and lessons to address challenges in equitable access, quality, and accountability through the “Improve Primary Health Care Service Delivery” project.
A participatory pragmatic EIR approach was applied to co-design and pressure test the implementation strategies to optimize the HEP roadmap (2020–2035). Fourteen woredas from agrarian and pastoral contexts were selected to pressure test HEP optimization strategies. Continuous adaptation tracking and fidelity monitoring were conducted throughout the project implementation period from April 2022 to September 2024. The HEP optimization implementation strategies, adaptations, and modifications were guided by frameworks such as Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies to ensure interventions fit local contexts.
The adaptations of implementation strategies resulted in implementation fidelity, which improved maternal and child health service coverage, strengthened community health program units, enhanced referral systems through Networks of Care (NoCs), and contextualization of service delivery for pastoralist communities. While most strategies were retained and repackaged for scale, others—including performance-based incentives and governance restructuring—were deprioritized because of feasibility, policy, and sustainability considerations. Adaptations were guided through iterative learning and stakeholder engagement and clustered into four broad areas: contextualization of service delivery models, strengthening community engagement, streamlining quality improvement and NoCs approaches, and refining accountability mechanisms. Stakeholder engagement was pivotal in balancing fidelity with contextual adaptations, fostering trust and sustainability. Despite challenges such as resource constraints, sociocultural barriers, and infrastructure limitations, systematic monitoring and iterative learning processes facilitated the refinement of scale-up strategies.
Adaptive implementation science effectively optimizes health programs in complex and dynamic contexts. Participatory co-design, stakeholder engagement, and systematic frameworks facilitated the development and refinement of strategies that improved service quality, access, and accountability in diverse PHC settings.
Background
Ethiopia’s Primary Health Care (PHC) system—anchored by the Health Extension Program (HEP)—has been instrumental in expanding equitable access to primary health services, particularly maternal and child health care, in rural and underserved areas [1–3]. However, the HEP/PHC program has faced several challenges; poor infrastructure, service fragmentation, poor quality of care, and weak accountability [3–6]. Core components of HEP/PHC, including the delivery of maternal and child health interventions, community engagement practices, and adherence to service delivery protocols, were weakly implemented as intended [2] {Assefa, 2020 #99} limiting the programs potential impact on achieving universal health coverage, and the Sustainable Development Goals [7].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider hospital systems desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Biruk Bogale, Gizachew Tadele Tiruneh, Mesele Damte Argaw, Agumasie Semahegn, Nebreed Fesseha, Chala Tesfaye, Mikiyas Teferi, Hillina Tadesse, Mebrie Belete, Addis Girma, Temesgen Ayehu, Yibeltal Siraneh, Yibeltal Kifle, Bezawit Mesfin Hunegnaw, Dessalew Emaway. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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