Table 1.

Anticipated strengths, challenges and possible strategies to support Ethiopian PHCG scale-up in relation to a framework for successful scale-up

Strengths	Potential challenges	Potential strategies
Success factor for scale-up (domain): attributes of the intervention being scaled up
Simplifies existing clinical decision support.	Guidance differs from previous training.	Integrate within PHC preservice training programmes.
	Facilities not resourced to deliver the care outlined in PHCG.	Central Pharmaceuticals Fund and Supply Agency prepared to support implementation. Monitor medication stock-outs closely.
Success factor for scale-up (domain 2): attributes of implementers
Working with non-state partners for technical support.	Weak leadership at the district and PHC levels.	Link with existing transformation agenda to strengthen leadership.
Success factor for scale-up (domain 3): chosen delivery strategy
Phased implementation using a cascade model of training. Decentralised through regions and zones. Horizontal, integrative approach.	Lack of familiarity with peer-to-peer learning.	Pioneer programmes of clinical mentorship, for example, building on the successful models used for scale-up of task-shared HIV care and the Health Extension Programme.45
Success factor for scale-up (domain 4): attributes of the adopting community
PHCG is advantageous for the PHC worker and compatible with their core tasks. PHC workers motivated by being able to deliver improved care to patients.	Unwillingness of PHC workers to consult the guideline during consultation.	Behavioural change communication strategies will be developed to inform patients why their providers will be consulting guidance. Promotion of an all-learning culture during training. Ultimately move towards using tablet-based versions of the guide.
	Innovation of facility-based training may not be well-received because of benefits of off-site training.	District (‘woreda’) health office to recognise high-performing facilities. Recognise training as part of continuing professional development.
	Additional training may be needed to enable task-sharing for new areas of healthcare (non-communicable diseases/mental health) to health centre level.	Integrate PHCG into vertical programme inservice training (eg, the WHO Mental Health Gap Action Programme) and preservice training. Expanding the database of training cases.
	Sustainability: declining use and adherence to PHCG over time.	Institutionalise quality improvement (including clinical audit): ASSET to adapt and test. Link PHCG adherence to performance incentive mechanisms and health insurance requirements. Increase accountability to the community by strengthening the community-based Health Development Army and revitalisation of community clinical fora.
	High turnover of rural health workers.	Work with the PHCG approach of building capacity to train health workers locally.
Success factor for scale-up (domain 5): sociopolitical context
Strong political leadership. Strengthens core policy initiative. Strong country ownership.	Change of leadership.	Maintain the broad base for buy-in.
Success factor for scale-up (domain 6): research context
Collaboration with ASSET project increases chances of ‘learning by doing’.	Research may be perceived as slow and as an unrelated activity.	Build capacity in operational research. Engage implementers in setting the research question. Communicate research findings in a timely manner.

ASSET, heAlth Systems StrEngThening in sub-Saharan Africa; PHC, primary healthcare; PHCG, Primary Health Care Clinical Guidelines.