In Ethiopia, immunization coverage (DTP3 vaccination) ranges from 26% to 93% across regions, with most regions falling short of the national target (90%). In decentralized health systems, such as Ethiopia, successful outcomes rely on strong subnational capacity to manage basic services such as immunization. The Ministry of Health (MOH) has prioritized the role of Regional Health Bureaus (RHBs) in providing technical oversight to districts for immunization. JSI adapted the “Standard Competencies Framework for the Immunization Workforce” (WHO 2018) for the Ethiopian context to identify skill gaps of RHB staff and develop targeted plans of technical assistance to address them. Presented at 6th Global Symposium on Health Systems Research (HSR2020), November 8-12, 2020.

1. Building the Capacity of
Subnational Health Managers
as a Critical Component of
Decentralized Health Systems:
Emerging Findings from
Ethiopia
Lisa Oot, Rebecca Fields, Adriana Almiñana, Belayneh Dagnew, Daniel Girma, Elena Herrera, Natasha Kanagat
Corresponding author: Lisa Oot, lisa_oot@jsi.com
Presented at 6th Global Symposium on Health Systems Research,
November 8-12, 2020 Photo: Bill & Melinda Gates Foundation

2. Introduction
• In Ethiopia, immunization coverage (DTP3 vaccination) ranges from 26% to 93%
across regions, with most regions falling short of the national target (90%).
• In decentralized health systems, such as Ethiopia, successful outcomes rely on
strong subnational capacity to manage basic services such as immunization.
• The Ministry of Health (MOH) has prioritized the role of Regional Health Bureaus
(RHBs) in providing technical oversight to districts for immunization.
• JSI adapted the “Standard Competencies Framework for the Immunization
Workforce” (WHO 2018) for the Ethiopian context to identify skill gaps of RHB
staff and develop targeted plans of technical assistance to address them.

3. Methods
• JSI developed a self-assessment questionnaire
based on the competency framework to
gauge RHB staff capacity on 14 competencies
for immunization.
• RHB staff in four regions self-administered the
assessment at baseline (N=58) and midline 9-
10 months later (N=61), rating their
competency on a Likert-style scale (Figure 1).
• JSI analyzed baseline data in Excel and
provided tailored technical support to each
RHB based on baseline findings.
• RHB staff in all regions had multiple
opportunities to gain competency in skills
critical to RI programming and receive on-job
training from JSI staff during joint supervision
visits to health facilities.
Figure 1: Scale for self-assessing competency for each immunization program management competency area

4. Results
• Midline self-assessments indicated an
increase from 27% to 49% in the
number of “fully competent” or
“expert” responses.1
• Table 1: Across each competency
area, respondents reported
improvements in competency
Develop technical presentation using
appropriate data ↑ 27%
Capacity building to lower level staff ↑ 34%
Manage funds and determine the allocation
of resources for immunization ↑ 22%
Develop multi-year and annual plans ↑ 28%
Coordinate with non-governmental
organizations on planning/funding of
services ↑ 30%
Identify gaps in HR needs ↑ 12%
Provide high quality supportive supervision ↑ 32%
Data analysis, interpretation, and use ↑ 16%
Conduct data quality self-assessments ↑ 8%
Create an EPI microplan ↑ 30%
Conduct EPI performance review ↑ 26%
Supply and vaccine management ↑ 10%
Use of Quality Improvement tools ↑ 29%
Immunization safety measures and policies ↑ 13%
Table 1: Percent point change baseline to midline of responses
denoting "competent" or "expert“ for 14 competency areas
1 Note: endline not yet conducted

5. Conclusions
• The use of self-assessments to estimate competency indicate early gains in capacity
building of subnational health management teams.
• Although self-assessments are subject to respondents’ perceptions of their skills, they
nonetheless represent a practical and nimble way to begin to gauge the capacity of the
immunization workforce during the course of a project or in lieu of large costly
evaluations.
• Application of the competency framework and self-assessments is an approach that
could be integrated into the MOH in Ethiopia as a standard, low-tech/effort process to
identify capacity building needs of its staff and provide targeted technical assistance.
• Given limited time and resources for capacity building, this process can help to identify the
competencies needed within teams at each level of the health system and then efficiently target
resource allocation or technical assistance to build skills in specific areas. In addition, the approach
can be used to gauge how well the MOH’s own capacity building initiatives are working.