Moving from expanding access to ensuring quality: lessons from the high-quality health systems framework in Ethiopia

Abstract Background Over the past two decades, Ethiopia has substantially improved access to care. However, inadequate progress towards achieving the SDG targets in maternal and child mortality and stalled declines in neonatal mortality signal the need to consider quality of care beyond access. Few studies have comprehensively assessed the quality of primary health care, particularly amid multiple recent and ongoing challenges to the health system. This study aims to address this gap and inform programmatic decisions, including resource allocation, by assessing the quality of essential health services in Ethiopia. Methods This study used data from 1,158 facilities and 10,649 clients attending family planning, antenatal care, and sick child services, collected during the 2021–22 Ethiopia Service Provision Assessment, to estimate healthcare readiness and quality as conceptualized by the High-Quality Health Systems framework. This comprehensive approach extends beyond traditional measures of quality of care by integrating a systems-level perspective and multilevel concepts of structural readiness inputs, service delivery processes, and client-centered outcomes across three domains: Competent Systems, Evidence-based Care, and Positive User Experience. We constructed 98 indicators and calculated overall, domain, and subdomain scores, scaled 0-100%, interpreted as the percentage of applicable quality standard indicators met. We conducted a descriptive analysis of scores at national and subnational levels by region, facility type, managing authority, and urban-rural setting. Results Nationally, facilities met 46% of quality standards. Domain scores were lowest for Evidence-based Care (32%) and higher for Competent Systems (51%) and Positive User Experience (50%). The results demonstrated notable geographic disparities; Addis Ababa often scored highest, whereas Somali and Gambella consistently lagged. Hospitals and health centers scored highest overall and across domains, while health posts and rural health facilities, which provide community health promotion, scored higher in the Competent Systems subdomains of Continuity and Integration and Population and Health Management, reflecting the reach of Ethiopia’s community health strategy. Conclusions The low performance in evidence-based care suggests that provider adherence to clinical standards is a key area for targeted quality improvement efforts. Concerted efforts to address regional disparities in service provision can drive continued progress and foster equitable access to high-quality healthcare.