Usaid Transform - Primary Health Care Project - Public Financial Management Enhancement

USAID TRANSFORM:
PRIMARY HEALTH CARE PROJECT

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT
ASSESSMENT REPORT
Recommended Citation: Transform: Primary Health Care Project. April 2022. Public Financial
Management Assessment Report. Rockville, MD: Abt Associates.
DISCLAIMER
This training material is made possible by the generous support of the American people through the United States Agency for International
Development (USAID) under a cooperative agreement number of AID-663-A-17-00002 USAID Transform Primary Health Care Activity. The
contents are the responsibility of the Ethiopian Ministry of Health and do not necessarily reflect the views of USAID or the United States
Government.
ACKNOWLEDGMENTS
The authors would like to thank the following experts for their unreserved efforts and commitment to
the development of this report:
Hailu Zelelew, Abt Associates Home Office
Tarekegn Abate, Transform: Primary Health Care Project Central Office
Tewodros Tekle, Transform: Primary Health Care Project Central Office
Zewdu Tesfaye, Transform: Primary Health Care Project Central Office
Girma Balcha, Transform: Primary Health Care Project Oromia Regional Office
Zelalem Gashaw, Transform: Primary Health Care Project Amhara Regional Office
Nigatu Afework, Transform: Primary Health Care Project SNNP Regional Office
USAID Transform Primary Health Care Project regional managers and cluster staff
The authors would like to acknowledge the following team members for their contribution in closely
reviewing this report and providing valuable comments:
Dr. Mengistu Asnake, Transform: Primary Health Care Project Central Office
Dr. Binyam Desta, Transform: Primary Health Care Project Central Office
Girma Kassie, Transform: Primary Health Care Project Central Office
Bonnie Kligerman, Abt Associates Home Office
Jhana McGaugh, Abt Associates Home Office
Dr. Bekele Belayihun, Transform: Primary Health Care Project Central Office
Ismael Ali, Transform: Primary Health Care Project Central Office
CONTENTS
Acronyms .................................................................................................................................. iii
Executive Summary ................................................................................................................. iv
1. Background ........................................................................................................................ 1
2. Introduction ....................................................................................................................... 3
2.1 Project Capacity Enhancement Support ................................................................................................. 3
2.2 PFM Major Achievements........................................................................................................................... 7
3. Objective of the Assessment .......................................................................................... 10
4. Methods/Approaches ....................................................................................................... 11
4.1 Sampling and Data Collection ................................................................................................................ 11
4.2 Study Settings ............................................................................................................................................. 11
4.3 Study Design and Instruments................................................................................................................ 12
4.4 Limitation of the Assessment ................................................................................................................. 12
4.5 Data Analysis .............................................................................................................................................. 12
5. Results............................................................................................................................... 13
5.1 Knowledge about Project’s PFM Capacity-enhancement Work ................................................... 13
5.2 Usefulness of PFM Capacity-enhancement Materials ....................................................................... 13
5.3 Training of PFM Trainers/Master Trainers .......................................................................................... 14
5.4 Rollout of PFM Training ........................................................................................................................... 15
5.5 Progress in Applying PFM Learning after PFM Training ................................................................... 15
5.6 PFM Mentoring Practices ......................................................................................................................... 16
5.7 Assessment of Current PFM Practices and Performances .............................................................. 17
5.8 Institutionalization and Sustainability of Project Support on PFM ................................................. 17
6. Conclusions and Recommendations .............................................................................. 20
6.1 Conclusions................................................................................................................................................. 20
6.2 Recommendations ..................................................................................................................................... 20
References ................................................................................................................................ 22
Annex A: Concept Note ......................................................................................................... 23
Annex B: Indicators for Woreda Classification .................................................................... 26
Annex C: Assessment Study Tools ........................................................................................ 27
PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | i

LIST OF TABLES
Table 1. Results of Random Follow-up Visits, 2017/18 (Q4)–2019/20 (Q4) ................................................ 9
Table 2. Data Collection Level, Subject/Source, and Methodology...............................................................11
Table 3. KII Summary ................................................................................................................................................13
Table A1. Data Collection Level, Subject/Source, and Methodology............................................................24
LIST OF FIGURES
Figure 1. Numbers of PHC Level Finance Staff that Received PFM Rollout Training ................................. 4
Figure 2. Number of Health Facilities that Received PFM Mentoring of Staff............................................... 5
Figure 3. PHC PFM Enhancement Technical Support Pathway ........................................................................ 6
Figure 4. Trends in Health Budget Share ............................................................................................................... 7
Figure 5. Revenue Generated, and Health Budget Allocated and Used in Health Sector, 2016/17 to
2019/20 (Birr millions) .............................................................................................................................. 8
Figure 6. Trends in IBEX and Audit Coverage and PHC Facilities................................................................... 8
PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | ii

ACRONYMS
BOFED Bureau of Finance and Economic Development
CBHI Community-Based Health Insurance
HCF Health Care Financing
KII Key Informant Interview
MOH Ministry of Health
PFM Public Financial Management
PHC Primary Health Care
RHB Regional Health Bureau
RRU Revenue Retention and Utilization
SNNP Southern Nations, Nationalities, and Peoples’ (Region)
TOT Training of Trainers
WOFED Woreda Office of Finance and Economic Development
WorHO Woreda Health Office
ZHD Zonal Health Department
ZOFED Zonal Office of Finance and Economic Development
PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | iii

EXECUTIVE SUMMARY
Background
The USAID Transform: Primary Health Care project works to improve public financial management
(PFM) at the primary health care (PHC) level. These improvements are expected to strengthen the
management and performance of the public health system at all levels and in turn contribute to
preventing child and maternal deaths in the project’s 399 target woredas located in Amhara, Oromia,
Sidama, Southern Nations and Nationalities Peoples’ (SNNP), and Tigray regions. The project conducts a
wide range of activities to strengthen PFM capacity amongst local counterparts at the PHC level.
The purpose of this assessment was to understand the extent to which PFM capacity enhancement is
progressing; to examine whether the project’s PFM capacity-enhancement activities are relevant,
effective, and sustainable; and to generate evidence for improving capacity-enhancement efforts and use
of PFM tools and templates. The findings will inform current capacity and practices, the scope and
magnitude of PFM capacity-enhancement support, and the relevance and use of PFM operational and
mentoring guides.
The study used qualitative and quantitative data, and covered a sampling of PHC-level entities in
woredas and zones in Amhara, Oromia, SNNP, and Tigray.
Results
Almost all respondents reported being familiar with the PFM capacity-enhancement efforts of the
Transform: Primary Health Care project and its activities including identification of capacity gaps,
development of training materials and implementation guidelines, and mentoring and training. Most
respondents felt that the project’s support has improved PFM practices.
Most of the health system key informant interview respondents expressed that PFM capacity-
enhancement materials are comprehensive, user-friendly, and useful as standardized references.
However, separate from this assessment, after reviewing the materials, a professional instructional
design consultant recommended that some of them be reorganized and restructured by a professional
instructional designer.
Regional, zonal, and woreda respondents from both the finance and health sectors expressed very
positive reactions to the selection of PFM master/training of trainers (TOT) trainers, the conducting of
TOT training, and the rollout of PFM training to PFM practitioners at the primary hospital and health
center level. In response to open-ended questions about the continued rollout of PFM training, some
respondents suggested the need to provide financial, equipment, and logistics support for training. They
also suggested support for the organization of peer-learning fora at which best-performing facilities
share their experience with PFM, and strengthening supportive supervision of facilities’ PFM activities.
The respondents also expressed appreciation for the PFM mentoring guides and tools. Most of them
acknowledged that mentoring had improved PFM at the PHC level, and they strongly voiced the need to
continue this practice.
Local counterparts’ engagement during guidelines and tools development, capacity building, mentoring,
and supervision as well as when the materials and tools are used is critical for local ownership,
transition, institutionalization, and sustainability. However, key informants acknowledged that regions
have not achieved full institutionalization of PFM capacity-enhancement efforts. They also mentioned
high PFM staff turnover as a major challenge to institutionalization and sustainability of the PFM system.
PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | iv

Conclusions
The assessment showed that the Transform: Primary Health Care project’s PFM capacity-enhancement
efforts at the PHC level, conducted in collaboration with government counterparts, is positively viewed
by respondents from the finance and health sectors at all levels. It also found that project woredas and
PHC health facilities are demonstrating improved PFM practices as compared to non-project
intervention woredas. To continue this, regional finance and health authorities recommended expanding
the PFM trainings to more local-level trainers and trainees in view of high staff turnover, and to woredas
in which the project does not currently work.
While the existing PFM guidelines, training materials, and the mentoring guide and tools are very much
appreciated by respondents, an independent consultant pointed to the need for revising and updating
those materials by instructional media experts.
Though there have been significant efforts to institutionalize PFM capacity enhancement within the
government system, full institutionalization is still at an early stage. The project needs to continue its
support for full institutionalization.
Recommendations
Improve and update training materials: The Transform: Primary Health Care project together
with government counterparts should work with instructional media and adult learning experts to
review training materials to incorporate into them instructional design for adult learning.
Fully operationalize health care financing structures: Government counterparts at all levels
in collaboration with development partners need to work to fully institutionalize PFM capacity-
enhancement responsibility within government structures.
Work on staff retention and additional training: To address turnover of training staff,
especially those who attended TOT, the project and government counterparts must make a
concerted effort to train additional trainers, and the government should adopt measures that will
increase PFM staff retention at all levels.
Advocate for financing of PFM capacity building in the government budget: The project
needs to advocate for adequate government budget for training, mentoring, and supervision as part
of PHC PFM capacity enhancement in the public health system.
Facilitate peer learning: The project should facilitate discussions between regional health
bureaus/zonal health departments and bureaus of finance and economic development on how to
organize and finance experience sharing and learning between high- and low-performing woredas
and health facilities.
Strengthen integration of PFM supervision in routine integrated supportive supervision:
The project needs to advocate for incorporation of PFM indicators in the integrated supportive
supervision checklists of the regions.
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1. BACKGROUND
The USAID Transform: Primary Health Care project works to improve public financial management
(PFM) at the primary health care (PHC) level. These improvements are expected to strengthen the
management and performance of the public health system at all levels and in turn contribute to
preventing child and maternal deaths in the project’s 399 target woredas located in Amhara, Oromia,
Sidama, Southern Nations and Nationalities Peoples’ (SNNP), and Tigray regions.
The project, in collaboration with local counterparts, developed prototype PFM guidelines for use at the
PHC level and customized them for regional use. The guidelines were used in PFM trainings of trainers
(TOT) at regional and zonal levels, and PFM rollout trainings at woreda and health facility levels. The
project also supported government counterparts in developing a PFM mentoring guide and program, and
putting them into practice. In summary, the project’s PFM capacity enhancement work leading up to the
assessment included:
Developed prototype PFM guidelines for use at the PHC level and customized them for regional use.
Reviewed and planned to improve existing PFM training materials.
Provided PFM training for woreda finance and economic development office (WOFED) and woreda
health office (WorHO) staff.
Provided technical assistance to government counterparts in conducting TOT sessions for staff from
regional health bureaus (RHBs), bureaus of finance and economic development (BOFEDs), and zonal
offices of finance and economic development (ZOFEDs), enabling them to roll out trainings on the
PFM guidelines to WOFED, WorHO, and health facility personnel.
Developed PHC-level PFM mentoring guide—the first of its kind in Ethiopia—and introduced it to
RHB, BOFED, zonal health department (ZHD), and ZOFED personnel so they understand what
mentoring means, how and who undertakes mentoring, their roles and responsibilities, etc. The
guide helps to standardize and institutionalize PFM mentoring in the public sector.
Selected a cadre of PFM mentors comprising experts who received training on the PFM guidelines
from among government counterpart (RHBs, ZOFED, and WOFED).
Provided orientations to mentors on the use of the PFM mentoring guide.
Launched a PFM mentoring program at the PHC level to provide continuing professional
development of mentees, to improve their PFM job performance.
Provided onsite PFM mentoring to managers and finance personnel in WorHOs and health facilities
using government and project PFM mentors.
The purpose of this assessment was to understand the extent to which PFM capacity enhancement is
progressing; to examine whether the project’s PFM capacity-enhancement activities are relevant,
effective, and sustainable; and to generate evidence for improving capacity-enhancement efforts and use
of PFM tools and templates.
The study methodology comprised the collection of quantitative and qualitative data through the review
of secondary documents (primarily project and government reports), and doing key informant
interviews (KIIs) with finance and health authorities and experts at regional, zonal, and woreda levels
and with health facility management and finance teams at primary hospitals and health center levels.
PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 1

The study covered Amhara, Oromia, SNNP, and Tigray.1 In Amhara, Oromia, and SNNP, a total of
three zones, one from each region, were randomly selected for participation.2 In each of the zones, two
woredas, one high- and one low-performing, were selected using a purposive sampling technique based
on the total project target woredas at the time of the assessment.3 The primary hospital and two health
centers (one high-performing and one low-performing) in each woreda were also covered. KIIs were
done with representatives from RHBs, bureaus of finance and economic development (BOFEDs), ZHDs
and zonal offices of finance and economic development. Of the 54 key informants, 39 were from the
health sector and 15 were from finance authorities at regional, zonal, and woreda levels. All respondents
had worked for more than one year in their organization and position at the time of the assessment.
Over 90% of them reported that they have financial management roles and responsibilities in their
positions at the time of the assessment.
1 Formerly part of SNNP Region, Sidama was established as a region and integrated into the project. This occurred after the
study methodology was developed, and therefore Sidama is not included as a study region.
2 In Tigray, zonal-level data were not collected because the region is relatively small and zones there do not have a strong
legal and administrative mandate in PFM.
3 The Transform: Primary Health Care project with consent from government counterparts classified the 399 woredas in
each of its target regions as high-, medium-, and poor-performing based on their health service delivery performance
against 12 public health tracer indicators focused on maternal, reproductive, and child health services.” The 12 indicators
(see Annex B) were selected and classification of performance level was agreed during the project design stage.

2. INTRODUCTION
In 1998, Ethiopia introduced the Health Sector Reform Program and in the ensuing years has been
implementing, a broad range of health care financing (HCF) reforms. These reforms included allowing
health facilities at the PHC level to retain and use revenue they collect in ways that will improve their
delivery of health services. This demands a comprehensive public financial management (PFM) system
that is customized to the health sector and the capacity to conduct financial practices in line with best
experiences in the health sector (FDRE MOH 2017).
The USAID Transform: Primary Health Care Project provides comprehensive technical support on PFM
to WorHOs and service delivery facilities in 3994 woredas (districts) located in five of Ethiopia’s
regional states (Amhara, Oromia, SNNP, Sidama, and Tigray) to improve the provision of quality health
care services. The project is expected to contribute to preventing child and maternal deaths and
support the Ministry of Health (MOH) and regional health bureaus (RHBs) in attaining the four
transformational agendas of the Health Sector Transformation Plan II (FDRE MOH 2021).
One of the key approaches of the transformational agendas is to create a high-performing PHC system.
Improved PFM performance will contribute to woreda transformation by enabling successful
implementation of the Ethiopian Health Centers Reform Implementation Guideline, an important
component of the woreda transformation agenda.
At the PHC level, the USAID Transform: Primary Health Care project is expected to achieve the
following high-level results: 1) Strengthened management and performance of the public health system at
the regional, zonal, woreda, and PHC (primary hospitals, health centers, and health posts) level; 2)
Increased sustainability of high-quality service delivery across the continuum of care; 3) Improved
household and community health practices and health-seeking behaviors; and 4) Enhanced program
learning to impact policy and programming related to preventing child and maternal deaths. Improved
PFM practices will contribute to all four results listed above. To this end, the project has conducted
several activities and achieved important results including in areas of enhancing PFM capacity at the PHC
level.
2.1 Project Capacity Enhancement Support

With technical support from the USAID Transform: Primary Health Care project, the MOH together
with RHBs and bureaus of finance and economic development (BOFEDs) developed various prototype
PFM capacity-enhancement materials for use at the PHC level through participatory and consultative
processes. These prototypes were then adapted by regions for use. The first of those materials was the
Public Financial Management Guidelines For Primary Health Care (Primary Hospitals, Health Centers,
and Woreda Health Offices) (FDRE 2018). The guidelines were developed based on broader finance
manuals and guidelines of the Ministry of Finance and Economic Development and the focus regions’
BOFEDs. The guidelines contain tools and templates that PFM practitioners and managers use in their
day-to-day PFM work. It is the first of its kind for the health system in Ethiopia—no PFM guidelines for
the PHC level existed previously.
4 At the time of the assessment.

The prototype PFM guidelines were then customized to regional contexts of the project’s target regions
(Amhara, Oromia, SNNP, and Tigray) and translated into three local languages (Amharic, Oromifa, and
Tigrigna).5
The project also supported the design of training materials to accompany the guidelines, like PowerPoint
presentations and practical exercises, which are being used for training of trainers (TOT) and rollout
sessions. TOTs on the use of the PFM guidelines were held for 150 selected Bureau of Finance and
Economic Cooperation and Zonal Office of Finance and Economic Cooperation senior PFM experts
who then rolled out the training to 1,598 WOFEDs, WorHOs, and health facility personnel over two
years (Figure 1).
Figure 1. Numbers of PHC Level Finance Staff that Received PFM Rollout Training
Total 1,598
Year
2018/19 1,375
2017/18 223
Number of participants
The comprehensive Public Financial Management Mentoring Guide for Primary Health Care (Primary
Hospitals, Health Centers, and Woreda Health Offices) (FDRE MOH 2018) was also developed to
provide a standard and defined approach to PFM leaders and mentors on how to conduct mentoring. It
now is being used by regional and zonal levels (by RHBs, BOFEDs, and ZHDs and offices of finance and
ZOFEDs to enhance the capacity of PFM staff, and to institutionalize and optimize performance related
to PFM at the woreda and PHC level.
The step-by-step mentoring guide is a reference for after in-person technical training on the PFM
guidelines. It supports the training with practical on-the-job PFM tools and templates as presented in the
PFM guidelines, and with detailed checklists to standardize mentoring across regions and different levels
of the government finance and health sectors. Staff at 493 health facilities were mentored through
2019/20 (Figure 2).
5 USAID Transform: Primary Health Care Project (August 2018). Prototype, later adapted by Amhara, Oromia, SNNP, and
Tigray RHBs and translated into the working languages of the respective regions.

Figure 2. Number of Health Facilities that Received PFM Mentoring of Staff
Total 493
2019/20 35
Year
2018/19 223
2017/18 235
Number of HF
Mentoring is introduced after training has been rolled out, to complement the training and further
support and enhance PFM capacity building. At the time of the assessment, project and government of
Ethiopia mentors had provided an orientation for 167 mentors and onsite PFM mentoring for 1,464
health facility managers and key financial personnel from 493 health facilities located in 89 intervention
woredas of the four intervention regions (USAID Transform: Primary Health Care Project 2019).
In addition, after some practice on PFM rollout training, the project conducted a review of the training
materials and resources used in its PFM capacity-enhancement interventions determine if any elements
needed improvement. An instructional design consultant was commissioned to review the instructional
aspects of PFM guidelines, tools, and training materials (Yeshiwas 2020). The consultant observed that
overall, the content and materials are good and provided concrete recommendations to further enhance
these resources as a comprehensive training package. Recommendations included:
Learning objectives require better alignment with the content for several of the sub-component
technical areas.
The materials can be reorganized and packaged as one training manual for participants.
The PowerPoint presentations can be enhanced by streamlining text and simplifying the wording.
The review of the PFM training materials helped government counterparts, Transform: Primary Health
Care project staff, and other stakeholders to understand the key steps taken to implement project
capacity-enhancement interventions for improving the PFM system and to learn about the strengths and
weaknesses of the implementation process. The review concluded that the materials produced with
project support are well organized and simple to understand for intended professionals to serve as
guides and reference materials. However, the review also disclosed that the materials lack some aspects
of professional instructional design, and they need to be re-organized and restructured.
The technical support pathway for the project’s PFM work is presented as Figure 3.

Figure 3. PHC PFM Enhancement Technical Support Pathway
• Advocated use of IBEX system at PHC level • Organized technical working group
• Supported installation of IBEX at PHCs that consisting of senior experts from the
had infrastructure like electricity and MOH, USAID Health Financing
computer system Improvement Program, and USAID
• Conducted PFM guidelines need • Provided IBEX training on how to use the Transform: Primary Health Care
assessment and identified gaps • Conducted consultative workshop system in collaboration with RHBs, bureaus of project’s HCF team to re-design and
• Developed Terms of Reference on PFM mentoring guide financing and economic development, and refine existing PFM training materials
based on identified gaps development zonal health offices and offices of financing and • Organized consultative workshops with
• Conducted consultative workshop • Designed mentoring checklist economic development stakeholders to further enrich the draft
Aug. 2018 Dec. 2018 July 2019 Oct. 2020
• Established pool
of 150 trainers Delivered
Developed Established Produced
(TOTs) Developed Launched consultant report
prototype PFM draft PFM
• Trained 1,598 PFM IBEX on the review of
PFM mentoring training
financial mentoring system at instructional
guidelines team of 167 package for
personnel on guide PHC level aspects of PFM
for PHC mentors PHC
PFM guidelines
Nov. 2018 Mar. 2019 June 2020
Way forward
• Customized PFM guidelines for • Translated the PFM mentoring guide • Commissioned a consultant • Finalize the draft PFM
regional context and use into local language (Amharic, to review and provide training package and
• Translated guidelines into local Oromifa, and Tigrigna) recommendations on the disseminate to relevant
languages (Amharic, Oromifa, • Printed and distributed the mentoring instructional aspects of partners for use.
and Tigrigna) guide to stakeholders existing PFM guidelines
• Continue providing
• Printed and distributed the • Provided orientation for mentors on • Conducted a review and capacity-enhancement
guidelines to partners how to conduct mentoring proposed recommendations support at PHC level to
• Conducted onsite PFM mentoring for to improve the existing PFM institutionalize and
1,020 health facility managers and key training materials sustain PFM at the PHC
financial personnel from 28 primary level
hospitals and 205 health centers

2.2 PFM Major Achievements
The above technical support and advocacy efforts contributed to several improvements in PFM, budget
allocation, and implementation of the revenue retention and utilization (RRU) HCF reform over the
years. These have led to major results in increasing the amount of revenue retained, the government
budget share allocated (Figure 4), and budget spent/utilized in the health sector in its intervention
woredas over the last four consecutive years.
Figure 4. Trends in Health Budget Share
15 15 15 15
15
13 14 14
10 10 10 10
2016/17 2017/18 2018/19 2019/20
% of budget allocated to the WorHO out of the total Woreda administrion budget
HSTP Target
Project targer
The RRU reform allows public hospitals and health centers to collect, retain, and use their user fee
revenue for the quality improvement activities that they prioritize, such as procurement of drugs,
medical supplies, medical equipment, audio-visual materials for health education, and investments in basic
infrastructure—such as electric power and water supplies, and constructing and renovating health
facilities—that play a role in improving the quality of health service delivery.
The amount of retained revenue collected by PHC facilities increased by 60%, from just under 0.5 billion
Birr in 2016/17 (baseline) to 0.85 billion Birr in 2019/20 (Figure 5). The amount of retained revenue
spent/used over this same period doubled, from 0.4 billion Birr in 2016/17(baseline) to 0.8 billion Birr in
2019/20. In most health facilities, about 75% of retained revenue was spent on drugs and medical
supplies. Some health facilities used the revenue to build maternal waiting rooms, which is believed to
increase the uptake of institutional delivery.
The number of woredas that have allocated ≥15% of their total budget to the health sector also has
increased. At the beginning of the project (2017/18), only 27% of woredas allocated ≥15% of their total
budget to the health sector. In 2019/20, this increased to 46% of woredas, nearly doubling.

Figure 5. Revenue Generated, and Health Budget Allocated and Used in Health Sector, 2016/17 to
2019/20 (Birr millions)
449.10
Total Internal revenue 553.80
generated by PHCUs 708.50
850.50
3,781.20
General government 5,498.20
health budget 5,921.90
7,438.00
3,789.50
General government 5,485.90
health expenditure 6,036.50
7,434.60
2016/17 2017/18 2018/19 2019/20
The average proportion of the budget spent on health as a share of total woreda government
expenditure in the intervention woredas improved from 12% in 2017/18 to 15% in 2019/20. The woreda
health sector utilization rate out of the total allocated budget improved from 92% in 2017/18 to 94% in
2019/20. Internal revenue generated by health facilities as a share of total health facility budget accounts
in 2016/17, 2017/18, 2018/19, and 2019/20 was 16.5%, 18.0%, 18.0%, and 15%, respectively. The share
fell in 2019/20 due to a decrease in visits to health facilities in the second half of the year because of the
COVID-19 pandemic.
To digitalize the financial management information system, and to advance the methods and practices of
collecting, analyzing, processing, and disseminating reliable financial information at health facilities, the
project provided technical assistance to 117 facilities to install IBEX software and training to their
finance staff in its use (Figure 6). The project also provided technical support on auditing in the form of
training, mentoring, supportive supervision, performance review meetings, and so forth, which increased
audit coverage at PHCs.
Figure 6. Trends in IBEX and Audit Coverage and PHC Facilities
935
Number of HFs
591
223
121
71 117
40
6
2017/18 2018/19 2019/20 Total
Year
IBEX installation at HFs Audit coverage at HFs

A comparison of data collected during random follow-up visits in Quarter 4 of 2017/18 and Quarter 4
of 2019/20 shows improvement in selected indicators relevant to PFM practices: percentages of facilities
doing an audit of their finances, including RRU, for the preceding fiscal year increased from 75% to 85%
in primary hospitals and 57% to 66% in health centers. Auditing helps ensure proper PFM is being done
(Table 1).
In addition, health center reimbursement requests paid by the community-based health insurance
(CBHI) schemes increased from 52% to 69%. Health facilities can more fully and quickly improve the
quality of health services when they receive accurate and on-time payments from CBHI schemes for
services they provide to CBHI beneficiaries.
Table 1. Results of Random Follow-up Visits, 2017/18 (Q4)–2019/20 (Q4)
Visited 2017/18 2018/19 2019/20

Institution Indicators Q4 Q4 Q4
N 142 204 160
Identify gaps in relation to human, financial, and material
73.8% 84.0% 87.0%
resource in health facilities, and provide timely solution
WorHO
WorHOs facilitate auditing of PHC accounts at a minimum
annually and audit reports reviewed by the facility 45.8% 70.0% 78.0%
governing board
N 384 888 848
Health post Health Extension Workers play a role in strengthening the
relationship between health centers and satellite health 70.3% 77.0% 84.0%
posts in use of RRU
N 360 498 566
HCs started retaining and utilizing its internal revenue 97.5% 98.0% 99.0%
HC finances, including RRU, audited in the last fiscal year 57.8% 65.0% 66.0%
Health center HCs in CBHI woredas provide health care services to
79.2% 85.0% 93.0%
CBHI beneficiaries
Last quarter’s reimbursement request paid by the CBHI
52.5% 60.0% 69.0%
scheme
N 40 110 67
PHLs prepare long-, medium-, and short-term
Primary 75.0% 81.0% 85.0%
procurement plans
hospital
PHLs finances, including RRU, audited in the last fiscal year 70.0% 72.0% 79.0%
PHLs provide health care services to CBHI beneficiaries 77.5% 83.0% 92.0%
Note: HC=health center, N= number, PHL=primary hospital

3. OBJECTIVE OF THE ASSESSMENT
The purpose of the assessment was to examine whether PFM capacity-enhancement activities of the
Transform: Primary Health Care project, developed and implemented with the collaboration of
government counterparts, are relevant, effective, and sustainable; and to generate evidence for
improving the activities, including the use of PFM tools and templates. (See Annex A for the concept
note for the assessment.)
The assessment asked the following major questions:
How comprehensive are the PFM guidelines, tools and templates/forms, mentoring guides, and
training materials developed with project support for PFM capacity enhancement?
Do visited health facilities and WorHOs have these materials?
Are the materials being used by health facility finance staff and management to guide PFM work at
the PHC level?
What PFM capacity-enhancement approaches are being used for PHC?
How confident are government counterparts in owning and leading PHC-level PFM capacity-
enhancement efforts in the future?
How has the PFM work at the PHC level progressed? Has PFM performance improved?
How has the Transform: Primary Health Care Project’s PFM capacity-enhancement support
contributed to improving PFM performance?
• Which capacity enhancement support contributed the most and why?
• How is the support reviewed and perceived/rated by government counterparts?

4. METHODS/APPROACHES
4.1 Sampling and Data Collection
The study methodology included review of secondary documents (focusing on project and government
reports), KIIs with finance and health authorities/experts at regional, zonal, and woreda levels, and
health facility management and finance teams at primary hospitals and health center levels. Both the
quantitative and qualitative data were collected to inform current capacity and practices, scope and
magnitude of PFM capacity-enhancement supports, relevance and use of PFM operational and mentoring
guides and their use.
Four project focus regions were covered in this study. Three zones, one from each of the largest three
regions, namely, Amhara, Oromia, and SNNP, were randomly selected and covered. Zonal-level data
were not collected in Tigray as the region is relatively small and zones do not have a strong legal and
administrative mandate in PFM. Representatives from RHBs, BOFEDs, as well as ZHDs and ZOFEDs
participated in KIIs. In each selected zone, purposive sampling was used to select two woredas, one
high- and one low-performing, to participate in the assessment. The primary hospital and two health
centers (one high-performing and one low-performing) were also covered. In total, 54 key informants
(39 from the health sector and 15 from finance authorities at regional, zonal, and woreda levels) were
interviewed.
4.2 Study Settings

As the health arm of the woreda government, the WorHO owns PHC facilities and oversees facility
operations. In this way, the WorHO is key to PHC performance. On average, one woreda is expected
to own and lead 20 health posts, 4 health centers, and a primary hospital.
At the time of study, the project covered 399 woredas grouped into 30 clusters (zones) in the four
targeted regions (Amhara, Oromia, SNNP, and Tigray). The assessment team collected data at the
following administrative levels and PHC facilities, from the aforementioned subjects/sources and using
the methodology indicated in Table 2.
Table 2. Data Collection Level, Subject/Source, and Methodology
Administrative/
Geographic Number/ Data Sources and
Level Quantity Subjects Sample Sizes Methodology
Prototype PHC-PFM Guidelines,
PFM Guidelines of Amhara,
Oromia, SNNP, and Tigray regions
Secondary
PHC-PFM Instructional Media
Written materials document
Evaluation/Review report
Regions 4 review
Transform: Primary Health Care
Project quarterly and annual
reports, project briefs, etc.
RHB heads/reps
8 [1 rep x 2 subject type x 4 regions] KIIs
BOFED heads/reps
3 [1 per ZHD heads/reps
Zones 6 [1 rep x 2 subject type x 3 zones] KIIs
region] ZOFED heads/reps

Administrative/
Geographic Number/ Data Sources and
Level Quantity Subjects Sample Sizes Methodology
8 [2 per WOFED heads/reps 16 [1 rep x 2 subject type x 8
Woredas KIIs
zone] WorHO heads/reps woredas]
16 [1 primary
Health facility heads/reps 24 [1 rep x 2 subject type x 8
hospital and 1
Health facilities and finance and admin primary hospitals + 1 rep x 1 subject KIIs
health center
heads/reps type/interview x 8 health centers]
per woreda]
4.3 Study Design and Instruments

The study was carried out using a cross-sectional mixed methods approach that provided both a
quantitative and a qualitative assessment. The quantitative and qualitative data were collected
simultaneously, and questionnaires were used to gather data using both methods. A total of seven KII
tools with open-ended questions were developed and used with regional, zonal, and woreda health and
finance authorities, eight primary hospital management and eight primary hospital financial management
team members, and eight health center representatives. (See Annex C for the study tool
questionnaires.)
4.4 Limitation of the Assessment

The purpose of the assessment was to gather general information and feedback on the PFM capacity-
enhancement support provided by the project for use in improving its support over the remaining life of
the project and for systematizing institutionalization and transition of project-supported activities before
the project ends. Because of this limited purpose and scope, the sample size covered in the study is
limited. The study did not try to gauge the contribution of the project’s capacity-enhancement effort
beyond project sites.
4.5 Data Analysis

Quantitative and qualitative data collected were analyzed separately and then synthesized and
interpreted. The quantitative data were managed using Microsoft Excel. Descriptive statistics were
performed for all study variables.
For the qualitative data, the open-ended responses from the mixed-methods assessment were
transcribed for thematic content analysis using NVivo 12. A simple coding framework was developed
based on the primary assessment questions and served as a framework to identify repeating ideas and
emerging themes.

5. RESULTS
In total, 54 key informants (39 from the health sector and 15 from finance authorities at regional, zonal,
and woreda levels) were interviewed (Table 3). All respondents had worked for more than one year in
their organization and position at the time of the assessment. Over 90% of the key informants/
respondents reported that they had financial management roles and responsibilities in their positions.
Table 3. KII Summary
Average Average Years Percent of Managers/

Years of of Experience Financial Personnel
Number of Experience in in Current with Financial
Interviewee Organization Interviewees Institution Position Management Roles
7 (4 RHB +3
RHB and ZHD 12 3 71% (5/7)
ZHD)
7 (4 BOFED + 3
BOFED and ZOFED 12 7 100% (7/7)
ZOFED)
WorHO 8 4 2 100% (8/8)
WOFED 8 9 2 100% (8/8)
Primary hospital management 8 5 3 88% (7/8)
Primary hospital finance and
8 5 1 88% (7/8)
admin.
HC (both mgt and finance) 8 6 4 88% (7/8)
Total 54 91%
5.1 Knowledge about Project’s PFM Capacity-enhancement Work

Data gathered from all sources showed that substantial progress had been made in PFM, but also that
challenges remain in improving PFM in project intervention woredas and elsewhere.
Many of the respondents at BOFEDs and ZOFEDs, and RHBs and ZHDs, and most at WOFEDs and
WorHOs as well as health facility management and PFM staff are familiar with the project’s PFM
capacity-enhancement work. Among other things, capacity gap identification, development of training
materials and implementation guidelines, and coaching practices were well acknowledged as noticeable
project supports in addition to training. All respondents at RHBs and BOFEDs recognize that the
project provides PFM such support. Very few respondents at zonal, woreda, and health facility levels are
not aware of the support. Slightly over half of the respondents know the project because they have
attended the PFM training it organized. A significant number of respondents mentioned gaps
identification as the project’s major contribution, followed by development of training manuals and
implementation guidelines, and coaching and mentoring support.
5.2 Usefulness of PFM Capacity-enhancement Materials

The assessment asked respondents how they view the PFM capacity-enhancement materials and if they
use them in their day-to-day PFM work. All health and finance authorities at regional, zonal, and woreda
levels as well as health facilities reported that they have copies of the materials. The data collection team
was able to verify (by viewing) that all regional and zonal health and finance authorities and finance teams
at primary hospitals have all the materials. However, not quite three-fourths of WOFED, primary
hospital, and health center management, and only half of WorHO respondents were able to show those
materials to the data collectors.

All BOFED and ZOFED respondents reported that they have copies of PFM capacity enhancement
materials, and they were also able to show copies of those materials for the data collectors. The
majority of respondents reported that they find the PFM capacity-enhancement materials
comprehensive, user-friendly, and useful as standardized references. In fact, all BOFED, ZOFED, and
WOFED respondents reported that the materials are useful beyond the PHC level and outside the
health sector. They also reported that they plan to customize the materials (PFM guidelines for PHC,
mentoring guide, and training materials and tools) to maximize their use and improve overall PFM
performance above the PHC level of the health sector and outside the sector. BOFEDs and ZOFEDs
also plan to distribute the customized materials to the relevant entities, and use them in training of
personnel in woredas and above the PHC level. At regional and zonal health authority levels, most of
them responded positively about using PFM materials above PHC level.
Most of the KII health system respondents expressed that PFM capacity enhancement materials are
comprehensive, user-friendly, and useful as standardized reference. However, as noted above,
professional instructional design reviewer recommended for revision of those materials by instructional
designer and some of the materials need to be re-organized and restructured accordingly.6
The project circulated a limited number of printed copies and provided electronic copies to all
trainees/practitioners. During the assessment, approximately three-fourths of respondents shared the
need to broadly distribute printed copies of the PFM guidelines for PHC and other materials to facilitate
uptake and utilization. This response underlined that PFM staff prefer to have printed copies of all these
materials for easy reference and use. Respondents also discussed the need to ensure continuous and
uniform use of the PFM resources through the mentoring process and integrating and aligning project
follow-up visit checklists with health sector integrated supportive supervision. Some respondents
mentioned the need to update procurement guidelines and procedures to the evolving national and sub-
national contexts using circulars or addendums, without changing the guidelines entirely.
5.3 Training of PFM Trainers/Master Trainers

All regional and zonal finance and health respondents reported that they are aware of the PFM TOTs
that Transform: Primary Health Care organized. A majority of them mentioned that printed and
electronic copies of the PFM guidelines for PHC, training materials, and group exercises were
disseminated during these trainings. Most reported that the PFM materials were comprehensive. Both
health and finance respondents were asked about readiness of master trainers in terms of understanding
PFM guidelines and training materials immediately after attending TOT sessions. Most of the health and
finance respondents deemed TOT attendees’ readiness as very good and good, respectively. Most of
health and all of finance respondents confirmed that TOT attendees are either good or very good, and
are ready to facilitate PFM training rollout.
A majority of respondents shared suggestions to inform future TOT rollout trainings, such as
standardizing the process for selecting trainers to ensure all trainers have adequate capacity, tailoring
training materials to the type and skill level of trainees, increasing the allotted time for trainings, and
conducting increased follow-up visits to provide on-the job support to the application of the training.
Respondents also strongly urged increasing the number of TOTs to expand the pool of master trainers
and reach all frontline PFM practitioners.
Respondents also had suggestions for key support needs after TOT rollout trainings including financial
support (for equipment, logistics, printing more copies of materials and translating them into sub-
6 Following the recommendation of the instruction media consultant, PFM training materials were redesigned by PFM technical
experts in collaboration with instructional media experts. These materials are professionally edited and formatted, and they
are ready for printing and/or digital circulation.

regional languages as needed, etc.) and organizing more experience sharing from best-performing
facilities/peer-learning facilitation, and supportive supervision. Some respondents noted opportunities to
leverage existing institutionalized resources for TOTs: RHBs and WOFECs could collaborate to get the
required budget for trainings, and WOFEC PFM experts could give on-the-job training to PFM
practitioners at the PHC level.
5.4 Rollout of PFM Training

Respondents from both finance and health sectors at regional, zonal, and woreda levels were asked to
assess progress in rolling out PFM training at the PHC level, in terms of reach, coverage, and target
group. According to all regional and zonal health respondents, and the majority of regional and zonal
finance respondents, the right people at WOFEDs and WorHOs, and primary hospitals and health
centers have attended PFM trainings. These include accountants, procurement officers, finance and
property administration process owners, audit and inspection owners, property administrators, cashiers,
and daily cash collectors. Most regional and zonal health and finance respondents recognized the
progress of the training rollout as good or very good. At the woreda level, more than half of WorHO
and one-third of WOFED respondents reported that rollout is good or very good. In contrast, one-
third of BOFED, ZOFED, and WOFED, and very few WorHO respondents indicated the rollout
progress is poor or fair.
Generally, the quality of PFM rollout training is affirmed positively by almost all respondents from
finance and health sectors at regional, zonal and woreda levels. In response to the quality of the training
roll-out, respondents suggested the need to select trainers based on assessed capacity— “select the
trainer after the training (TOT) is provided and do so through an exam.” Responses also showed a theme of
tailoring training tools to match the skill level of the targeted trainees and allocating adequate time for
the trainings.
5.5 Progress in Applying PFM Learning after PFM Training

The application of skills and knowledge learned during PFM training to workplace responsibilities is
critical to ensure PFM practices are conducted in health facilities. Post-training mentoring and follow-up
visits are interventions that are used to support PFM staff to use the new skills, PFM processes, and
tools. While most respondents from the RHBs, ZHDs, and WOFEDs reported that they conduct
follow-up visits to health facilities, only some BOFED, ZOFED, and WorHO respondents reported
doing so. The follow-up visits by the first two groups are encouraging as RHBs have better PFM capacity
within the health sector and WOFEDs have strong capacity and authority/delegation to lead and oversee
PFM at the woreda level. All regional, zonal, and woreda health and finance sector respondents reported
that the primary purpose of their follow-up visit is to provide on-the-job technical support. Most of
them also responded that they did follow-up visits to assess performance of PFM practitioners following
training. Only very few mentioned other reasons.
Most regional and nearly three-fourths of zonal health and finance sector respondents rated the
contribution of PFM training to improving PFM skills of staff as good and very good. At the woreda level,
almost all of health and more than half of finance respondents mentioned skills improvement after PFM
training as good or very good. A few finance sector respondents at the regional, zonal, and woreda
levels called it fair, and one out of four respondents both in health and finance sectors at the woreda
level responded that they do not know. The “fair” and “do not know” responses are areas for further
improvement. What is important to note is that no respondent reported the contribution of PFM
training in improving PFM skills as poor or very poor.
Key informants noted that several areas of post-training and post-mentoring performance improvement.
These include preparation of on-time and complete annual planning and budgeting documents such as

procurement plans; improvement in the monthly and annual reports and auditing performance,
specifically improved documentation/reporting procedures highlighted across respondents/ levels; and
improvement in planning/budgeting procedures as advantages of the PFM training and other capacity-
development support. Some respondents also mentioned improvements in procurement practices
following capacity-development interventions. One WOFED respondent said, “Budget is now prepared
before April of the year,” which is ahead of time for approval in June or July.
5.6 PFM Mentoring Practices

A major initiative that the Transform: Primary Health Care project introduced for improving PFM is
post-training mentoring of health facility PFM practitioners. When asked if mentoring took place, all
regional and zonal health sector participants responded affirmatively. In addition, many regional, zonal,
and woreda finance participants, and more than half of the WorHO participants responded that
mentoring was provided to relevant practitioners. At the health facility level, there is little difference in
the affirmative responses about mentoring between primary hospital management (6/8) and finance and
administration staff (5/8). Likewise, the majority of health center level respondents reported that there
was PFM mentoring.
Regarding timing of mentoring, respondents above the health facility level (RHB and ZHD, BOFED and
ZOFED, and WorHO and WOFED levels) indicated a range of responses. Overall, most of them
responded that mentoring practices occurred within one year after the training. At health facility level,
five out of eight primary hospital management, and most primary hospital finance and health center
respondents reported mentoring was conducted within six months after the training. Also overall,
respondents from higher-level health and finance sectors, those who lead mentoring or employ mentors,
and health facilities that receive mentoring services responded very positively, so one can conclude that
mentors from both the finance and health sectors are doing a good job.
In interviews, key informants underlined the need for mobilizing adequate resources to provide
comprehensive and continuous post-training mentoring to all health facilities. Additional responses
pointed to other challenges such as high turnover of both mentors and mentees and competing
priorities that could impact the timeliness of mentoring. The informants mentioned that periodic follow-
up/mentoring and supportive supervision visits immediately after trainings are key to improving PFM
capacity, quality, and practices, especially given the high staff turnover. This is important as less than half
of regional/zonal health and finance sector, and only one-fourth of WOFED respondents reported that
mentoring was provided within three months after rollout training. This implies that, unless done
immediately after training, mentoring can be compromised by high turnover of trainers who are also
mentors.
Use of the PFM mentoring guide and standard tools supports standardization and harmonization of
mentoring practices to better institutionalize such practices. All regional- and zonal-level health and
finance respondents reported that mentors attended training on the PFM guidelines for PHC and
orientation on use of the PFM mentoring guide. The same respondents all replied that mentors use
appropriate procedures and tools that are included in the guide.
However, WOFED respondents indicated that there is a major gap in mentoring capacity/readiness and
practices. Only regional and zonal professionals, mainly trainers, were expected to do mentoring, but for
practical capacity considerations and other reasons, WOFEDs are increasingly involved in supervision
and mentoring. The regional- and zonal-level MOH trainers and mentors orient the WOFED staff to the
mentoring approach. But according to the responses of WOFED participants, there is a low and uneven
use of the resources and tools during mentoring. This indicates that orientation of WOFED staff is not
uniform and requires attention to build the mentoring capacity of WOFEDs.

Comprehensiveness of PFM mentoring, in terms of covering all the necessary components of PFM, is
reported by all health and finance respondents at regional, zonal, woreda, and health facility levels. At
the regional and zonal level, the majority of health and all finance respondents characterized the
comprehensiveness of mentoring as good or very good. In contrast, only half of WorHO and WOFED
participants called it good. At the health facility level, more than half of both hospital management and
finance and administrative respondents, and most of the health center respondents said that the
comprehensiveness of mentoring is good or very good.
“Mentoring has helped us make a big difference in our PFM performance… mentoring should be continued.” –
Primary hospital respondent
The PFM mentoring guide and tools, and the mentoring practices are well appreciated by both finance
and health sector respondents. Most of them acknowledged that mentoring helped PFM improvement at
PHC level and strongly suggested the need to continue this practice in the future. This is in line with
anecdotal feedback that the project team received from both finance and health counterparts during
mentoring guide and tools development and use.
5.7 Assessment of Current PFM Practices and Performances

Health sector and finance respondents at regional and zonal levels responded that PFM practices related
to planning and budgeting, and budget execution practices at the PHC level is fair to good. Both health
and finance respondents reported that PHC facilities currently show strong planning, budgeting, and
budget execution practices.
All regional and zonal health respondents, and almost all regional and zonal finance respondents
reported that PHC facilities are submitting their annual budget on time. About three-fourths of both
health and finance respondents reported that PHC facilities improved their PFM practices following
technical support from the Transform: Primary Health Care Project. Additionally, over half of health and
most of finance authorities reported that PFM practices are better in project focus PHCs than in non-
project ones.
Most respondents revealed that PFM practices have improved following capacity enhancement support
provided by the project. At least three KII respondents – one ZOFED, one WOFED and one RHB –
explicitly mentioned that the quality and timeliness of planning and budgeting, and financial
administration practices and adherence to procedure; and one of them underlined the need to
introduce the same capacity enhancement practice in non-project intervention woredas.
Respondents particularly highlighted strongly improved performance in the areas of auditing and
reporting systems, and procurement in project woredas because of the trainings and other capacity-
development efforts by the project.
Respondents at health facilities also shared IBEX installation as a key benefit of the project in facilitating
improved PFM performance.
“We are increasingly receiving high quality budget on time.” – one ZOFED respondent
“Planning is now prepared in a participatory manner.” – one WOFED respondent
“There is strong improvement in financial administration practice and procedure that needs to reach other
woredas.” – one ZHD respondent
5.8 Institutionalization and Sustainability of Project Support on PFM

Institutionalization of PFM capacity-enhancement approaches and practices is only possible when local
counterparts play lead roles and/or are part of designing interventions, developing operational

guidelines, and executing capacity building. Local counterparts’ engagement during guidelines and tools
development, capacity enhancement, mentoring and supervision as well as use of materials and tools are
critical for local ownership, transition, institutionalization, and sustainability of outside support. Regional
and zonal health and finance authorities responded very positively regarding their and the lower
structures’ involvement in shaping PFM guidelines and mentoring guides and training materials;
conducting PFM TOT, training rollout, and training/orientation of mentors; mentoring practitioners; and
doing supervision, follow-up, and mentoring of PFM practices. Greater numbers of health and all of
finance sectors respondents at the regional and zonal levels recognized government involvement in the
process of PFM guidelines development as good or very good. The rating by finance sector respondents
is “relatively better,” which shows strong government involvement and leadership as finance is leading
PFM practices in the government system. Regarding development of the PFM mentoring guide, almost all
health and nearly three-fourths of finance sector respondents at the regional and zonal levels confirmed
government counterparts’ involvement as good or very good.
Respondents reported the importance of the increased number of staff trained in PFM best practices
that will contribute to sustainability of improved PFM processes and systems. The establishment of HCF
structures at woreda and zonal levels that are being operationalized in project focus regions and
facilitating experience sharing between project intervention woredas and non-intervention woredas
were viewed as key next steps for further institutionalizing and sustaining project gains. However, the
issue of high staff turnover was highlighted as a potential challenge to such efforts.
“Although a lot of trainings have been provided, health facilities still suffer from staff turnover, therefore,
continuous onsite training, mentoring, coaching and rollout trainings are needed to sustain progress,” said a key
informant from one of the RHBs.
Training of PFM practitioners at the PHC level is the most important capacity-improvement component
of Transform: Primary Health Care Project support. Following development of PFM guidelines and other
training materials in collaboration with government counterparts, the project engaged the same
counterparts in identifying the right experts for TOT. All the regional and zonal health and finance
respondents covered in this assessment said their involvement in selecting and training of trainers was
good or very good.
Regarding rollout of PFM training to PHC-level PFM practitioners, almost all regional- and zonal-level
health sector and all finance sector key informants reported that government counterparts’ involvement
was good or very good. Similarly, nearly three-fourths of regional and zonal health sector and almost all
finance respondents stated government counterparts’ involvement during training/orientation of
mentors was good or very good.
Respondents from both sectors and at all levels responded well on the government counterparts’
involvement in training, mentoring and supervision practices. Doing post-PFM training mentoring, follow-
up, and integrated supportive supervision is considered essential to supporting and promoting practical
use of knowledge and skills gained through training as well as appropriate and timely use of guidelines
and tools. All health and finance respondents at regional and zonal levels assessed government
counterparts’ involvement during mentoring as fair, good, or very good. Comparing these two groups,
more finance sector respondents asserted government counterparts’ involvement was very good than
did health respondents.
Slightly less than half of both health and finance respondents claimed government counterparts’
involvement in post-PFM training follow-up visits as good or very good. However, some finance
respondents declared it very good and nearly half of health sector respondents called it good.
Regarding the overall institutionalization status of PFM capacity building in the government system, more
than half of regional and zonal health and nearly all regional and zonal finance respondents believe that it

is somewhat institutionalized. Interestingly, more health sector respondents than finance respondents
said that it is not yet institutionalized.
Regional- and zonal-level health and finance representatives were asked about their level of confidence
in leading PFM capacity-building efforts at the PHC level. Finance respondents expressed more
confidence, as three-fourths of them reported their confidence level as good or very good. In contrast,
not quite half of health sector respondents reported their confidence as good; the rest of them said it is
fair or poor.
Overall, key informants acknowledged that full-fledged institutionalization of PFM capacity enhancement
efforts has not yet been achieved in the respective entities. Respondents affirmed there is a strong
government interest and commitment to institutionalize PFM capacity building, with one BOFED official
mentioning that “there is an initiative to institutionalize PFM capacity enhancement efforts by establishing HCF
structure at regional level.” The need to operationalize the HCF structure at all levels in the health system
is one of the recommendations that respondents made to improve institutionalization of PFM capacity.

6. CONCLUSIONS AND RECOMMENDATIONS
6.1 Conclusions
This study showed that the PHC-PFM capacity-enhancement efforts of the Transform: Primary Health
Care project in collaboration with government counterparts is positively rated by respondents at all
levels of both finance and health sectors. There is also consensus among regional and zonal respondents
that the project woredas and PHC health facilities have demonstrated improved PFM practices as
compared to non-project intervention woredas. A cross-cutting message was to expand the trainings to
more trainers and trainees in view of high staff turnover and to cover non-intervention woredas because
of the progress seen in the project woredas.
The development process of PFM guidelines, training materials, mentoring guide, and tools and
availability of these PFM materials in electronic and limited printed copy is appreciated by respondents.
However, some respondents at all levels strongly recommended the need to distribute printed copies of
the materials. The 2020 instructional design review done by an independent expert showed the need for
an instructional media expert to revise and update the materials, and this was successfully done.
Organization and conducting of TOTs and training rollouts were well received by all respondents.
However, high staff turnover of trainers and PFM practitioners was reported as an ongoing health
system challenge. PFM mentoring guidelines, tools, orientations, and practices also were well recognized;
however, respondents also noted that timing of mentoring following training varies from region to
region and facility to facility.
Though there has been significant movement toward institutionalization of the project-supported PFM
capacity enhancements into the government system, institutionalization is reported to be at an early
stage and full institutionalization is a long way off. Institutionalization needs continued support by the
project so project achievements are sustained.
6.2 Recommendations
1. Improve and update training materials: The PFM materials developed for capacity building
(training and mentoring) and actual PFM practices at the PHC level in project focus-woredas is
very encouraging. However, the assessment also revealed gaps that needs to be addressed. The
Transform: Primary Health Care project together with government counterparts and
instructional media and adult-learning experts should review the training materials to align them
better with instructional design for adult learning.
2. Fully operationalize HCF structures: Government counterparts at all levels need to work
toward fully operationalizing HCF structures at all levels, including staffing the structures with
professional experts. There is also a strong need for dialogue on operationalization of the HCF
structure with adequate PFM capacity at all levels. The project can collaborate with the USAID
Health Financing Improvement Program, which is working on institutionalization and transition
of first-generation HCF reforms in all project focus regions; PFM responsibility can be clearly
included in the roles and responsibilities of HCF structures.
3. Sustain and strengthen TOT capacity: Turnover of staff who became trainers after taking
the TOT training is reported to be a major challenge for institutionalization and sustaining
provision of PFM training and mentoring at the PHC level. In the remaining life of the project,
the project needs to strengthen its engagement with government counterparts to create
understanding on the sharing of roles and responsibilities to ensure successful institutionalization

and continued/sustainable PFM capacity at the PHC level by fully owning and housing PFM TOTs
at federal and regional levels.
4. Advocate for financing of PFM capacity building in the government budget: To
continue providing capacity building of PFM at the PHC level, there is a need to secure
government buy-in and commitment. Financing of capacity building (continuous training,
mentoring, and supportive supervision) by government is an important prerequisite. The project
needs to advocate for an adequate government budget for training, mentoring, and supervision
of practitioners as part of the PHC-PFM capacity enhancement in the public health system. Since
the assessment found that respondents, particularly those in health facilities, prefer to have
printed copy of PFM materials, the health sector needs to set aside (or secure from other
sources) adequate funding to print sufficient copies of the PFM materials and distribute them to
PFM staff at health facility level. Conducting PFM mentoring at PHC facilities soon after staff
attend PFM training (no longer than three months after training) is considered critical for PFM
capacity enhancement. Enhancing mentoring capacity of WOFEDs requires attention and
orientation of WOFED staff needs to be uniform.
5. Facilitate peer learning: Many respondents recommended experience sharing and learning
from best-performing woredas and health facilities to facilitate practical learning and experience
sharing among PFM peers. The project needs to facilitate discussions between RHBs/ZHDs and
BOFEDs on how to organize and finance experience sharing and learning between high- and
low-performing woredas and health facilities.
6. Strengthen integration of PFM supervision in routine integrated supportive
supervision: Leveraging and maximizing use of existing systems and resources is critical for
seamless institutionalization of PFM capacity-enhancement activities including training,
mentoring, and on-the-spot technical support when PFM is being done. In the remaining life of
the project, Transform: Primary Health Care needs to advocate for incorporation of PFM
indicators in the integrated supportive supervision checklists of regions.

REFERENCES
Federal Democratic Republic of Ethiopia (FDRE) Ministry of Health (MOH). November 2010 (EFY).
Health Sector Development Programme IV, 2010/11-2014/15. Addis Ababa.
———.2017. Health Care Financing Strategy 2017–2025. Addis Ababa.
———. August 2018. Public Financial Management Guidelines for Primary Health Care (Primary
Hospitals, Health Centers, and Woreda Health Offices). Addis Ababa.
———. December 2018. Public Financial Management Mentoring Guide for Primary Health Care
(Primary Hospitals, Health Centers, and Woreda Health Offices). Addis Ababa.
———. 2021. Health Sector Transformation Plan II, 2020/21–2024/25. Addis Ababa.
USAID Transform: Primary Health Care Project. 2019. Year 3 (Oct 2018–Sept 2019) Annual
Performance Report. Addis Ababa.
Yeshiwas, Takele. June 2020. Review report on accounts module, audit module, procurement module,
cash management module training materials and generate recommendations. Unpublished

ANNEX A: CONCEPT NOTE
Concept Note
Transform: Primary Health Care Project
Assessment of Public Financial Management Practices at the Primary Health Care Level
1. Background
The Government of Ethiopia (GOE) has a strong Public Financial Management (PFM) system that
institutionalized financial planning, budgeting, revenue collection, budget execution, procurement,
property administration, expenditure tracking, auditing and reporting. Ethiopia introduced, and has been
implementing, a broad range of health care financing (HCF) reforms for more than two decades,
including allowing health facility level revenue retention and use that demands strong PFM systems and
the capacity to conduct financial matters in line with accountable best practices in the health sector.
Successive USAID-funded projects have supported the GOE to initiate and implement these reforms,
including further enhancing the Ministry of Finance’s PFM legislation and operational guidelines, and
developing and operationalizing a prototype HCF reform implementation manual that included how to
retain and use revenue at the health facility level.
The USAID Transform: Primary Health Care Project provides comprehensive technical support to a
wide range of health system and service delivery issues in 360 woredas located in Ethiopia’s four largest
regions (Amhara, Oromia, SNNP, and Tigray) to improve the provision of quality health care. The
project is expected to contribute to reducing preventable child and maternal deaths, and supports the
Ministry of Health (MOH) and regional health bureaus (RHBs) in attaining the four transformational
agendas included in the GOE’s Health Sector Transformation Plan. These objectives are realized mainly
through improved management and performance of the health system, sustained quality of service
delivery across primary health care units (PHCUs), and transformed woredas.
One of the key approaches to transforming woredas is to create high-performing PHCUs by improving
PFM at the PHC level which is an important component of the Ethiopian Health Centers Reform
Implementation Guideline (EHCRIG). To systematize and support PFM, the Transform: Primary Health
Care Project supported development of prototype PFM guidelines for use at the PHC level that were
subsequently customized for use in the four target regions with technical assistance from the project.7
The project also supported a training of trainers (TOT) session in the use and application of the PFM
guidelines in the four regions, and rolled out training to enhance the capacity of woreda and health
facility PFM staff. A PFM mentoring guide was also developed with project support and is being used by
PFM leaders and supervisors at regional and zonal levels to enhance the capacity of PHC-level PFM staff,
and to institutionalize and optimize performance related to PFM at woreda and PHC facility levels.8
7 Federal Democratic Republic of Ethiopia Ministry of Health. August 2018. Public Financial Management Guidelines for
Primary Health Care (Primary Hospitals, Health Centers, and Woreda Health Offices). Rockville, MD: USAID Transform:
Primary Health Care Project, Abt Associates Inc.
8 Federal Democratic Republic of Ethiopia Ministry of Health. December 2018. Public Financial Management Mentoring
Guide for Primary Health Care (Primary Hospitals, Health Centers, and Woreda Health Offices). Rockville, MD:
Transform: Primary Health Care Project, Abt Associates.

2. Purpose
The purpose of this assessment is to understand the extent to which health facilities use and adhere to
appropriate and good PFM practices, and generate evidence on the contribution of the project’s PFM
capacity enhancement efforts to improve PFM at the PHC level.
3. Scope
The scope of the assessment is limited to evidence generation on the current status of good PFM
practices at the PHC level, and to understand the contribution of the Transform: Primary Health Care
project’s capacity building support to improve PFM.
At the time of study, the project covers 360 woredas that are grouped into 30 clusters (zones) in four
regions (Amhara, Oromia, SNNP, and Tigray). The assessment will collect data at the following
administrative/geographic levels, from the subjects/sources specified, and using the methodology
indicated in Table A1.
Table A1. Data Collection Level, Subject/Source, and Methodology
Administrative/
Geographic
Level Quantity Subjects/Sources Quantity Methodology
Secondary
document review,
Written materials TBD
mainly project
Regions 4 reports
RHB heads/reps 8 [1 rep x 2 subject type x Key informant
BOFED heads/reps 4 regions] interviews (KIIs)
4 [1 per ZHD heads/reps 8 [1 rep x 2 subject type x
Zones KIIs
region] ZOFED heads/reps 4 zones]
WOFED heads/reps 16 [1 rep x 2 subject type
Woredas 8 [2 per zone] KIIs
WorHO heads/reps x 8 woredas]
16 [1 primary Health facility 32 [1 rep x 2 subject type
hospital and 1 heads/reps Health x 8 primary hospitals + 1
Health Facilities KIIs
health center facility finance and rep x 2 subject type x 8
per woreda] admin heads/reps health centers]
The following major questions will be covered under the assessment:

How comprehensive are the PFM guidelines, tools and templates/forms, mentoring guides, and
training materials for PFM capacity enhancement?
Do visited health facilities and woreda health offices have these materials?
Are these materials being used by health facility finance and staff and management to guide PFM
work at the PHC level?
What PFM capacity enhancement approaches are being used for PHC?
How confident are government counterparts to own and lead PHC-level PFM capacity enhancement
efforts in the future?
How has the PFM work at the PHC level progressed? Are there improvements in PFM performance
of PHCs?
How has the Transform: Primary Health Care Project’s PFM capacity enhancement support
contributed to improving PFM performance?

Which capacity enhancement support contributed the most and why?
How is the project’s PFM support reviewed and perceived/rated by government counterparts?
4. Assessment team
The assessment will be conducted by project staff with government counterpart involvement as
appropriate and when available. Team members include:
Technical lead: The project has internal PFM expertise and this study will be led by a PFM subject
matter expert. It will assign one PFM expert to technically lead the assessment and provide technical
expertise in designing the study instruments, leading data collection and analysis, and identifying
lessons and areas for improvement. The Technical Lead will write the assessment report.
Regional coordinators: The project’s four regional PFM specialists will coordinate the assessment
in their respective regions.
Data collectors: A total of 12 data collectors will be engaged. The project’s four regional PFM
specialists will conduct the regional and zonal level KIIs. One data collector per woreda (8) will
conduct the woreda and health facility level interviews. Data collectors will be project or
government counterpart PFM specialists, as appropriate.
Data compilation and analysis team: Raw data will initially be compiled by Technical Lead and
potentially other site office technical team members (and then translated either using external
translation services or by site office teams TBD). Quantitative data analysis will be conducted by the
Technical Lead, with home office inputs. Qualitative data will be compiled and analyzed by a home
office analyst, with home and site office inputs.
5. Data collection, compilation, analysis, and duration

The interview and consent tools will be translated into local languages, i.e., Amharic, Afan Oromo and
Tigrigna, and administered in these languages. Response data will also be recorded on the tools in the
same local language in which the KII is conducted. The raw data in the local languages will be compiled
and translated into English.
Quantitative data will be compiled by SPSS version 25 using descriptive statistics. Qualitative data will be
organized and analyzed using Nvivo software with thematic analysis.
Data collection is anticipated to take 5 days including travel time per woreda. The regional and zonal
level KIIs are expected be conducted in coordination with data collection in the study woredas. It is
estimated that regional and zonal level KIIs will require two days per region.

ANNEX B: INDICATORS FOR WOREDA
CLASSIFICATION
List of 12 project indicators used by RHBs to classify woredas as high-, medium-, and low- performing
using HMIS data.
No. Indicator
1 CAR
2 ANC - 4 visits
3 SBA
4 Early PNC
5 Penta3 (< 1 year)
6 Tested Positive for Malaria: <5yr
7 Tested Positive for Malaria: All Ages
8 Children under two years with moderate malnutrition
9 Children under two years with severe malnutrition
10 Pregnant and lactating women who were tested for HIV and who know their results
11 Maternal deaths related to pregnancy or its management in a health facility
12 Early institutional neonatal death rate

ANNEX C: ASSESSMENT STUDY TOOLS

Key Informant Interview Questionnaire TOOL 1
Regional Health Bureau and Zonal Health Department Official
Assessment of the Status of Public Financial Management
Capacity and Practices at the PHC Level
INSTRUCTIONS FOR INTERVIEWER

This key informant interview is to be used when conducting interviews with Regional Health Bureau
(RHB) and Zonal Health Department (ZHD) heads/representatives. Find the manager or the most
senior person responsible at this level. After greetings, introduce yourself and who you work for, and
briefly explain the purpose of the assessment/interview, the interview process including duration, and
thank them for seeing you.
Use the following script to seek oral informed consent to take part in the interview:
“The purpose of this assessment is to gather data on public financial management (PFM) capacities
and practices at the PHC level and Transform: Primary Health Care Project PFM capacity enhancement
efforts so that the contributions of these efforts to improving PFM at the primary health care (PHC)
level can be assessed. If there are questions for which someone else is the most appropriate person to
provide that information, I would appreciate it if you could introduce me to that person. Any
information you provide as part of this interview will be kept confidential. Any reference to the
information you provide in our analysis will be made without mentioning or implicating your name in
any way.
Your participation in this assessment is completely voluntary. You do not have to agree to be in this
assessment, and you may change your mind at any time. If we should come to any interview question
you do not wish to answer, just let me know and I will go on to the next question; or you can stop the
interview at any time. You will not receive any payment or compensation for your participation in this
assessment.”
Indicate the consent response and provide additional information per the fields below:
Permission to proceed: Do you agree to participate in the interview? Yes ☐ No ☐
Interviewee name (and providing oral consent):_______________________________________
Interviewee position or title: ______________________________________________________
Interviewee qualification (type and level of education/certification):______________________
_______________________________________________________________________________
Region: ____________________________ Zone: ___________________________________
Name of RHB/ZHD: ______________________________________________________________
Interviewer name: _______________________________________________________________
Interviewer signature (confirming consent): ___________________________________________
Interviewer contact number: __________________ Date of interview/consent: ______________

I. General Questions
1. How long have you worked in the RHB/ZHD? _____________________________
2. How long have you worked in your current position? _______________________
3. Do you have a financial management role in your current position, including planning and
budgeting, budget execution, budget review and/or reporting?
Yes ☐ No ☐
II. Knowledge about Transform: Primary Health Care Project’s PFM Capacity Enhancement Work
1. Are you familiar with the PFM capacity enhancement support provided by the Transform:
Primary Health Care Project? Yes ☐ No ☐
2. If yes, how did you learn about the support provided by the project? Tick all that apply.
a) Attended PFM training ☐
b) A project PFM specialist informed me ☐
c) A co-worker told me about it ☐
d) A friend told me about it ☐
e) Heard about it during ARM ☐
f) At events where Transform: Primary Health Care project member(s) introduced
themselves ☐
g) Other ☐ Specify: ____________________________________________
_____________________________________________________________
3. What PFM capacity enhancement support has the Transform: Primary Health Care Project
provided to the regions, zones, woredas, and/or PHC facilities in the regions/zones? Tick all
that apply.
a) Identified capacity gaps ☐
b) Developed implementation guide ☐
c) Developed training manual ☐
d) Trained trainers ☐
e) Rollout training ☐
f) Provided coaching and mentoring ☐
g) Other ☐ Specify: ___________________________________________

III. Capacity Enhancement Materials
1. What PFM capacity enhancement materials (i.e., PFM Guidelines for PHC, PFM Mentoring
Guide, PFM tools, and PFM training materials) have been provided to the RHB/ZHD, woreda
health offices (WorHOs), and PHC facilities? Please list them:
a) ____________________________________________________________
b) ____________________________________________________________
c) ____________________________________________________________
d) ____________________________________________________________
2. Are these materials user-friendly? Yes ☐ No ☐ Don’t know ☐

3. If no, please specify the reason:________________________________________
__________________________________________________________________
4. Do you have copies of these PFM capacity enhancement materials?
Yes ☐ No ☐
5. If yes, please show me copies. Data collector to note:
a) Saw copies. Yes ☐ If yes, list PFM materials seen:
____________________________________________________________________
____________________________________________________________________
b) Did not see copies ☐

6. Do you use these materials in non-Transform: Primary Health Care Project intervention
woredas? Yes ☐ No ☐
7. If yes, how? Tick all that apply.
a) Distribute copies of these materials ☐
b) Training ☐
c) Other ☐ Specify: __________________________________________
______________________________________________________________
8. Do you use these materials above the PHC level?
Yes ☐ No ☐
9. If yes, how? Tick all that apply:
a) Customize materials for above PHC level ☐

b) Distribute copies of the materials ☐
c) Other ☐ Specify: __________________________________________
______________________________________________________________

IV. Training of PFM Trainers/Master Trainers
1. Are you aware of any PFM training of trainers (TOT) sessions that were conducted with
Transform: Primary Health Care Project support to develop a cadre of PFM master trainers
in your region/zone? Yes ☐ No ☐
2. If yes, what materials were availed for the PFM TOT?
a) PFM Guidelines for PHC – Printed copies ☐
b) PFM Guidelines for PHC – Electronic version ☐
c) Training materials (presentations) ☐
d) Group exercises (prepared) ☐
e) Pre- and post-training assessment tools ☐
f) Other ☐ Specify: ____________________________________________
3. Were the training materials used sufficiently comprehensive?
Yes ☐ No ☐ Don’t know ☐
4. If no, what critical PFM aspects were missed? _____________________________
___________________________________________________________________
5. After receiving TOT training, rate the readiness of the master trainers to rollout PFM training
to the PHC level:
Very poor ☐ Poor ☐ Fair ☐ Good ☐ Very good ☐ Don’t know ☐
6. What post-TOT support and reinforcement do master trainers need to facilitate rollout of
PFM training? Please list up to three suggestions:
a) ______________________________________________________________
______________________________________________________________
b) ______________________________________________________________
______________________________________________________________
c) ______________________________________________________________
______________________________________________________________
V. Rollout of PFM Training

1. Who were the trainees at the PFM rollout training sessions (i.e., those trained by the master
trainers)? Tick all that apply.
a) WOFED
i. Accountants ☐
ii. Procurement, Finance, and Property Admin (PFPA) Process Owner ☐
iii. Audit and Inspection Process Owner ☐
iv. Other ☐ Specify:_______________________________________
v. Don’t know ☐

b) WorHO
i. Plan and Program Officer ☐
ii. Medical Service Coordinator/Officer Process Owner ☐
iii. Other ☐ Specify: ______________________________________
iv. Don’t know ☐
c) Primary Hospitals
i. Procurement, Finance, and Property Admin (PFPA) Process Owner☐
ii. Accountant ☐
iii. Procurement Officer ☐
iv. Cashier ☐
v. Property Admin. Officer ☐
vi. Internal Auditor ☐
vii. Plan and Program Officer ☐
viii. Other ☐ Specify: _______________________________________
ix. Don’t know ☐
d) Health Centers
i. Procurement, Finance, and Property Admin (PFPA) Process Owner ☐
ii. Accountant ☐
iv. Cashier ☐
vii. Don’t know ☐
e) Other ☐ Specify:___________________________________________
_____________________________________________________________
2. Were all of these trainees frontline PFM practitioners for PHCs?
3. If no, approximately what percentage of the trainees were not frontline PFM practitioners at
PHC level? _________%
4. Do non-PHC level practitioners typically attend rollout trainings?
5. If yes, why? List reasons:
a) __________________________________________________________
b) __________________________________________________________
6. What training materials were used during the rollout training?
a) PowerPoint presentations ☐
b) PFM Guidelines for PHC ☐

c) Pre- and post- training knowledge assessment tool ☐
d) Group exercise or assignment ☐
e) Other ☐ Specify: __________________________________________
f) Don’t know ☐
7. Rate the progress of the PFM rollout training in Transform: Primary Health Care Project
woredas in your region/zone.
Very poor ☐ Poor ☐ Fair ☐ Good ☐ Very good ☐

8. Rate the quality of the training rollout in Transform: Primary health Care Project woredas in
your region/zone.

9. Do you have any suggestions for improving the speed of the rollout or quality of the
training?
Yes ☐ No ☐
10. If yes, please list your top suggestion(s):
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
11. Were rollout trainees given PFM Guidelines and other PFM reference materials for use in
their day-to-day PFM work?
VI. Progress in Applying PFM Learning after PFM Training

1. Do you make follow-up visits to PHCs and trainees after PFM training?
Yes ☐ No ☐
2. If yes, what is the purpose of your visits? Tick all that apply and add more, if needed.
a) To give on-the-job technical support ☐
b) To assess how PFM trainees perform PFM tasks after training ☐
c) Other ☐ Specify:____________________________________________
3. Has PFM training improved PFM capacity at PHC level in Transform: Primary Health Care
Project intervention woredas?

4. If yes, which areas of job performance do you think are the most improved?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
5. Rate the contribution of the PFM training in improving the PFM skills of staff at the PHC
level.
6. How do you know such improvements have been made? What is the evidence? What are
the indicators/measurements of improvement?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
VII. PFM Mentoring

1. Has PFM mentoring been provided to PFM practitioners at the PHC level?
2. If yes, approximately how soon following the PFM training did the first mentoring visit take
place?
a) Immediately after training within 3 months following the training ☐
b)Within 6 months after the training ☐
c) Within 1 year after training ☐
d)After 1 year following PFM training ☐
3. Who were/are the PFM mentors? Indicate the position/title of mentors below:
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
e) Don’t know ☐
4. Have the PFM mentors attended training on the PFM Guidelines for PHC and the PFM
Mentoring Guide?
5. When mentoring, do mentors use the procedures and tools included in the PFM Mentoring
Guide for PHC?

6. If yes, indicate which ones:
a) PFM mentoring goal worksheet Yes ☐ No ☐ Don’t know ☐
b) PFM mentoring goal action plan Yes ☐ No ☐ Don’t know ☐
c) PFM mentoring self-assessment tool (for mentor) Yes ☐ No ☐ Don’t know ☐
d) PFM mentoring assessment tool (for mentee) Yes ☐ No ☐ Don’t know ☐
e) PFM mentoring checklist for PHC Yes ☐ No ☐ Don’t know ☐
f) PFM mentee profile Yes ☐ No ☐ Don’t know ☐
g) PFM mentoring log book Yes ☐ No ☐ Don’t know ☐
h) PFM mentoring report format Yes ☐ No ☐ Don’t know ☐
i) PFM mentoring schedule Yes ☐ No ☐ Don’t know ☐
7. If no, why not? ______________________________________________________________
___________________________________________________________________________
8. When mentoring, do mentors use any other procedures or tools (not indicated in list of #6
above)?
9. If yes, list which ones: _________________________________________________________
___________________________________________________________________________
10. Rate how comprehensive the PFM mentoring was in terms of covering all of the necessary
components of PFM?
11. What challenges, if any, have you experienced or observed related to the overall mentoring
process?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) None ☐
12. How do you think these challenges can be addressed and the overall mentoring process be
improved?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________

VIII. Assessment of PFM Capacity Enhancement Activities
1. How effective is the PFM capacity enhancement support provided by the Transform:
Primary Health Care Project (through guidelines, tools, training, and mentoring) in improving
PFM capacity in your region/zone?
2. Rate the effectiveness of each capacity enhancement effort in improving PFM capacity of
those who receive it.
a) PFM Guidelines for PHC
b) PFM Mentoring Guidelines
c) PFM training
d) PFM mentoring
e) Provide any information you’d like to share to explain the above ratings:
____________________________________________________________________
____________________________________________________________________
3. Describe gaps that you have observed or areas for improvement that you recommend for
each capacity enhancement effort listed below:
a) PFM Guidelines for PHC: ________________________________________________
_____________________________________________________________________
b) PFM Mentoring Guidelines:______________________________________________
_____________________________________________________________________
c) PFM training practices:__________________________________________________
_____________________________________________________________________
d) PFM training materials:_________________________________________________
_____________________________________________________________________
e) PFM mentoring:_______________________________________________________
_____________________________________________________________________

IX. PHC-Level PFM Practices
1. How do you assess the current planning and budgeting practices of PHCs in the
region/zone? _______________________________________________________
__________________________________________________________________
Please tick any of the below practices that apply:
a) PHCs are preparing and submitting their annual budget in a timely manner ☐
b) PHCs’ work plans are in line with PFM guidelines and standards ☐
c) PHCs project realistic internal revenue and budgets accordingly ☐
d) PHCs effectively use PFM tools and templates such as Forms Ma/BeMa
1-3 and Ka/BeMa 1-3 ☐
e) Don’t know ☐
2. How has the budget execution practice evolved over the last two years?
__________________________________________________________________
__________________________________________________________________
a) PHCs better forecast and submit their monthly cash flow ☐
b) PHCs use appropriate procurement, purchasing, and payment templates, tools, and
forms ☐
c) PHCs follow correct budget initiation, approval, and execution authorities☐
d) PHCs involve their respective health facility boards at each critical PFM decision-making
stage ☐
e) PHCs submit financial execution reports using appropriate templates/forms ☐
3. Have you observed differences in PFM practices when comparing before and after the
Transform: Primary Health Project was working in your zone/region?
Yes ☐ No ☐
4. If yes, please describe the difference(s).
__________________________________________________________________
__________________________________________________________________
5. Have you noticed differences in PFM performance when comparing Transform: Primary
Health Care Project intervention woredas and non-project woredas?
Yes ☐ No ☐

X. Sustainability: Institutionalization and Transition of Project Support
1. Rate the level of involvement of the RHB/ZHD and other government counterparts such as
BOFED/ZOFED in the PFM capacity enhancement efforts in collaboration with the Transform:
Primary Health Care Project.
a) Developing the PFM Guidelines for PHC
b) Designing training materials
c) Conducting PFM TOT
d) Rollout PFM training
e) Developing the PFM Mentoring Guide
f) Training/orientation of mentors
g) Mentoring PFM practitioners
h) Conducting post- training follow-up visits
i) Supportive supervision
2. Rate the level of institutionalization of the capacity enhancement efforts (i.e., guidelines, tools,
training, and mentoring) in the government system at all levels.
[To be fully institutionalized, the guidelines, tools, training, and mentoring would be completely
integrated into the government system, and regularly and consistently planned for and used. It
also requires availability of the required structure and staffing at RHB, ZHDs and WorHOs levels
to train and mentor PHC staff.]
a) Overall rating of institutionalization

Fully Institutionalized ☐
Somewhat institutionalized ☐
Not yet institutionalized ☐
b) BOFED

c) RHB
d) ZoFEC
e) ZHD
f) PHC-Primary Hospitals
g) PHC-Health Center
3. Rate how confident you think government counterparts (health sector and finance) are to lead
PHC-level PFM capacity enhancement efforts?
4. What is the government’s plan to institutionalize PFM capacity enhancement efforts? What
structures and capacities are in place?
______________________________________________________________________________
______________________________________________________________________________
Don’t know ☐
XI. Overall Suggestions for Next Steps

1. In your opinion, what could the Transform: Primary Health Care Project do to improve the
delivery of its PFM training, mentoring, and other capacity enhancement activities at the
PHC level? _________________________________________________________________
__________________________________________________________________________
2. In your opinion, what could the government do to improve PFM capacity enhancement
supports and practices at the PHC level? Please provide suggestions for the following
government levels/institutions:

a) Federal level
i. MOH:_________________________________________________________
______________________________________________________________
ii. MOFEC:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
b) Regional level
i. BOFEC/BOFED:__________________________________________________
______________________________________________________________
ii. RHB:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
c) Zonal level
i. ZOFED:________________________________________________________
______________________________________________________________
ii. ZHD:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
d) Woreda level
i. WoFED:_______________________________________________________
______________________________________________________________
ii. WorHO:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
e) Health facility level
i. Primary Hospitals:_______________________________________________
______________________________________________________________
ii. Health Centers:_________________________________________________
______________________________________________________________
iii. Other:________________________________________________________
_____________________________________________________________

TOOL 2
Key Informant Interview Questionnaire
Regional Bureau and Zonal Department of Finance and Economic Development Official

This key informant interview is to be used when conducting interviews with Regional Bureau and
Zonal Department of Finance and Economic Development/Cooperation heads/representatives. Find
the manager or the most senior person responsible at this level. After greetings, introduce yourself
and who you work for, and briefly explain the purpose of the assessment/interview, the interview
process including duration, and thank them for seeing you.
any way.
assessment.”
Interviewee name (and providing oral consent):________________________________________
Interviewee position or title: _______________________________________________________

_______________________________________________________________________________
Region: _____________________________ Zone: __________________________________
Name of Bureau/Department:______________________________________________________
Interviewer name: ________________________________________________________________
Interviewer signature (confirming consent): ____________________________________________
Interviewer contact number: __________________ Date of interview/consent: _______________

1. How long have you worked in the Regional Bureau (or Zonal Department) of Finance and
Economic Development/Cooperation (BOFED/C)? ____________
2. How long have you worked in your current position? ________________

budgeting, budget execution, budget review, auditing, and/or reporting?
Yes ☐ No ☐
4. If yes, what do think are the major PFM-related challenges in the health sector?
___________________________________________________________________________
___________________________________________________________________________
f) Heard about it during technical assistance/supportive supervision ☐

g) At events where Transform: Primary Health Care project member(s) introduced
themselves ☐
h) Other ☐ Specify: ___________________________________________

_____________________________________________________________
provided to the regions, zones, woredas, and/or PHC facilities in the regions/zones? Tick all
that apply.


Other ☐ Specify: ____________________________________________________
_____________________________________________________________________
4. Does BOFEC/D/ZOFED benefit from Transform: Primary Health Care Project’s capacity
enhancement efforts? Yes ☐ No ☐
5. If yes, describe how.

a) ___________________________________________________________
___________________________________________________________
b) __________________________________________________________
__________________________________________________________
c) __________________________________________________________
__________________________________________________________

Guide, PFM tools, and PFM training materials) have been provided to BOFED/ZOFEDs,
RHB/ZHDs, woreda health offices (WorHOs) and PHC facilities? Please list them:
a) ____________________________________________________________
b) ____________________________________________________________
c) ____________________________________________________________
d) ____________________________________________________________
2. Are these materials user friendly? Yes ☐ No ☐ Don’t know ☐
3. If no, please specify the reason: ________________________________________

___________________________________________________________________
Yes ☐ No ☐

____________________________________________________________________
____________________________________________________________________

6. Are any of the PFM materials useful for BOFEC/D/ZOFED to customize for use above the PHC
level and/or for other sectors?
7. If yes, which materials have you/do you plan to customize? Tick all that apply.
a) PFM Guidelines for PHC ☐
b) PFM Mentoring Guide ☐
c) PFM training materials ☐
d) PFM tools ☐
e) Other ☐ Specify:____________________________________________
8. How have you/do you plan to use them? Tick all that apply.
a) Distributing copies of the materials ☐
b) Training in relevant woredas ☐
c) Customize materials for above PHC level ☐
d) Other ☐ Specify: ___________________________________________
IV. Training of PFM Trainers/Master Trainers
1. Are you aware of any PFM training of trainers (TOT) sessions that were conducted with
Transform: Primary Health Care Project support to develop a cadre of PFM master trainers
in your region/zone? Yes ☐ No ☐
2. If yes, what materials were availed for the PFM TOT?
a) PFM Guidelines for PHC – Printed copies ☐
b) PFM Guidelines for PHC – Electronic version ☐
c) Training materials (presentations) ☐
d) Group exercises (prepared) ☐
e) Pre- and post-training assessment tools ☐
f) Other ☐ Specify: ____________________________________________
3. Were the training materials used sufficiently comprehensive?
4. If no, what critical PFM aspects were missed?

__________________________________________________________________
__________________________________________________________________

5. After receiving TOT training, rate the readiness of the master trainers to rollout PFM training
to the PHC level:
6. What post-TOT support and reinforcement do master trainers need to facilitate rollout of
PFM training? Please list up to three suggestions
a) _______________________________________________________________________
_______________________________________________________________________
b) _______________________________________________________________________
_______________________________________________________________________
c) _______________________________________________________________________
_______________________________________________________________________
V. Rollout of PFM Training

1. Who were the trainees at the PFM rollout training sessions (i.e., those trained by the master
trainers)? Tick all that apply.
a) WOFED
i. Accountants ☐
iv. Other ☐ Specify:_______________________________________
v. Don’t know ☐
b) WorHO
ii. Medical Service Coordinator/Officer Process Owner ☐
iii. Other ☐ Specify: ______________________________________
i. Procurement, Finance, and Property Admin (PFPA) Process Owner☐
ii. Accountant ☐
iv. Cashier ☐
d) Health Centers

ii. Accountant ☐
iv. Cashier ☐
vii. Don’t know ☐
e) Other ☐ Specify:___________________________________________
__________________________________________________________

PHC level? _________%


a) __________________________________________________________
__________________________________________________________
b) __________________________________________________________
__________________________________________________________

c) Pre- and post- training knowledge assessment tool ☐
e) Other ☐ Specify: __________________________________________
______________________________________________________________
f) Don’t know ☐
woredas in your region/zone.
your region/zone.

9. Do you have any suggestions for improving the speed of the rollout or quality of the
training?
Yes ☐ No ☐

a) ___________________________________________________________
___________________________________________________________
b) ___________________________________________________________
___________________________________________________________
c) ___________________________________________________________
___________________________________________________________
VI. Progress in Applying PFM Learning after PFM Training

Yes ☐ No ☐
c) Other ☐ Specify:____________________________________
__________________________________________________
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
5. Rate the contribution of the PFM training in improving the PFM skills of staff at the PHC
level.

a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
VII. PFM Mentoring

place?
b)Within 6 months after the training ☐
d)After 1 year following PFM training ☐
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
Mentoring Guide?
Guide for PHC?

7. If no, why not? _____________________________________________________
__________________________________________________________________
above)?
9. If yes, list which ones:
__________________________________________________________________
__________________________________________________________________
components of PFM?
process?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) None ☐
improved?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
VIII. Assessment of PFM Capacity Enhancement Activities

1. How effective is the PFM capacity enhancement support provided by Transform: Primary
Health Care Project (guidelines, tools, training, and mentoring) in improving PFM capacity in
your region/zone?

c) PFM training
d) PFM mentoring
____________________________________________________________________
____________________________________________________________________
a) PFM Guidelines for PHC: ______________________________________________
___________________________________________________________________
b) PFM Mentoring Guidelines:_____________________________________________
___________________________________________________________________
c) PFM training practices:_____________________________________________
___________________________________________________________________
d) PFM training materials:________________________________________________
___________________________________________________________________
e) PFM mentoring:______________________________________________________
___________________________________________________________________
IX. PHC-Level PFM Practices

1. How do you assess the current planning and budgeting practices of PHCs in the
region/zone?
__________________________________________________________________
__________________________________________________________________

a) PHCs are preparing and submitting their annual budget in a timely manner ☐
b) PHCs’ work plans are in line with PFM guidelines and standards ☐
c) PHCs project realistic internal revenue and budgets accordingly ☐
d) PHCs effectively use PFM tools and templates such as Forms Ma/BeMa 1-3 and Ka/BeMa 1-3 ☐
e) Don’t know ☐
2. How has the budget execution practice evolved over the last two years?
__________________________________________________________________
__________________________________________________________________

a) PHCs better forecast and submit their monthly cash flow ☐
b) PHCs use appropriate procurement, purchasing, and payment templates, tools, and
forms ☐
c) PHCs follow correct budget initiation, approval, and execution authorities☐
d) PHCs involve their respective health facility boards at each critical PFM decision-making
stage ☐
e) PHCs submit financial execution reports using appropriate templates/forms ☐
3. Have you observed differences in PFM practices when comparing before and after the
Transform: Primary Health Project was working in your zone/region?
Yes ☐ No ☐
4. If yes, please describe the difference(s).

__________________________________________________________________
__________________________________________________________________
5. Have you noticed differences in PFM performance when comparing Transform: Primary
Health Care Project intervention woredas and non-project woredas?
Yes ☐ No ☐
X. Sustainability: Institutionalization and transition of project support

1. Rate the level of involvement of the RHB/ZHD and other government counterparts such as
BOFED/ZOFED in the PFM capacity enhancement efforts in collaboration with the Transform:
Primary Health Care Project.
a) Developing the PFM Guidelines for PHC
b) Designing training materials

c) Conducting PFM TOT

d) Rollout PFM training

e) Developing the PFM Mentoring Guide

f) Training/orientation of mentors

g) Mentoring PFM practitioners
h) Conducting post- training follow-up visits

i) Supportive supervision
2. Rate the level of institutionalization of the capacity enhancement efforts (i.e., guidelines,
tools, training, and mentoring) in the government system at all levels.
[To be fully institutionalized, the guidelines, tools, training, and mentoring would be
completely integrated into the government system, and regularly and consistently planned for
and used. It also requires availability of the required structure and staffing at RHB, ZHDs and
WorHOs levels to train and mentor PHC staff.]
a) Overall rating of institutionalization

b) BOFED
c) RHB
d) ZoFEC
e) ZHD
f) PHC-Primary Hospitals

g) PHC-Health Center
3. Rate how confident you think government counterparts (health sector and finance) are to
lead PHC-level PFM capacity enhancement efforts?
4. What is the government’s plan to institutionalize PFM capacity enhancement efforts? What
structures and capacities are in place?
_________________________________________________________________________
_________________________________________________________________________
Don’t know ☐
XI. Overall Suggestions for Next Steps
delivery of its PFM training, mentoring, and other capacity enhancement activities at the PHC
level? ____________________________________________________________________
_________________________________________________________________________
government levels/institutions:
a) Federal level
i. MOH:_________________________________________________________
______________________________________________________________
ii. MOFEC:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
b) Regional level
i. BOFEC/BOFED:__________________________________________________
______________________________________________________________
ii. RHB:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________

c) Zonal level
i. ZOFED:________________________________________________________
______________________________________________________________
ii. ZHD:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
d) Woreda level
i. WoFED:_______________________________________________________
______________________________________________________________
ii. WorHO:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________

Woreda Health Office Official 3

This key informant interview is to be used when conducting interviews with Woreda Health Office
(WorHO) heads/representatives. Find the manager or the most senior person responsible at this level.
After greetings, introduce yourself and who you work for, and briefly explain the purpose of the
assessment/interview, the interview process including duration, and thank them for seeing you.
any way.
assessment.”
Interviewee name (and providing oral consent):_______________________________________
Interviewee position or title: ______________________________________________________

_______________________________________________________________________________
Region: _______________________________ Zone: _______________________________
Name of WorHO: ________________________________________________________________
Interviewer name: _______________________________________________________________
Interviewer signature (confirming consent): __________________________________________
Interviewer contact number: __________________ Date of interview/consent: _____________

1. How long have you worked in the WorHO? _____________________________
Yes ☐ No ☐
f) At events where Transform: Primary Health Care introduced itself ☐
g) Other ☐ Specify: ____________________________________________

_____________________________________________________________
provided to the WorHO and/or PHC facilities in the woreda? Tick all that apply.
g) Other ☐ Specify: ___________________________________________

Guide, PFM tools, and PFM training materials) have been provided to the WorHO and PHC
facilities in the woreda? Please list them:
a) ____________________________________________________________
b) ____________________________________________________________
c) ____________________________________________________________
d) ____________________________________________________________

__________________________________________________________________
Yes ☐ No ☐

____________________________________________________________
____________________________________________________________
IV. Rollout of PFM Training

1. Who were the trainees at PFM rollout training sessions? Tick all that apply.
a) WOFED
i. Accountants ☐
iv. Other ☐ Specify: _______________________________________
v. Don’t know ☐
b) WorHO
ii. Medical Service Coordinator/ Officer/ Process Owner ☐
iii. Other ☐ Specify: _______________________________________
ii. Accountant ☐
iv. Cashier ☐

vi. Internal auditor ☐
d) Health Centers
ii. Accountant ☐
iv. Cashier ☐
vii. Other ☐ Specify:________________________________________
viii. Don’t know ☐
e) Other ☐ Specify:___________________________________________

PHC level? _________%
a) __________________________________________________________
__________________________________________________________
b) __________________________________________________________
__________________________________________________________

c) Pre- and post- training knowledge assessment tools ☐
e) Other ☐ Specify: __________________________________________
f) Don’t know ☐
woredas in your woreda.

your woreda.

9. Do you have any suggestions for improving the quality of the training?
Yes ☐ No ☐
a) ___________________________________________________________
___________________________________________________________
b) ___________________________________________________________
___________________________________________________________
c) ___________________________________________________________
___________________________________________________________
11. Were trainees given PFM Guidelines and other PFM reference materials for use in their day-
to-day PFM work?
V. Progress in Applying PFM Learning after PFM Training

Yes ☐ No ☐

c) Other ☐ Specify:______________________________________________
3. Based on information gathered during your visits to PHCs, do trained PFM staff from PHCs
have the same positions that they had when they attended the training?
4. If yes, approximately what percentage of them have the same position that they had when
trained? _________%
5. If no, what percentage are outside of the PFM system? ________%
6. Are trained PHC PFM staff promoted after receiving the training?
7. If yes, what percentage are still in a PHC-level PFM role but in a different position?
___________%
8. If yes, what percentage left or are no longer in the PHC PFM system? ___________%


10. If yes, rate the overall contribution of the PFM training in improving the PFM skills of staff
at the PHC level.

a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
VI. PFM Mentoring

place?
b) Within 6 months after the training ☐
d) After 1 year following PFM training ☐
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
e) Don’t know ☐
Mentoring Guide?

Guide for PHC?
7. If no, why not? _____________________________________________________________
__________________________________________________________________________
above)?
__________________________________________________________________________
__________________________________________________________________________
components of PFM?
11. What do you believe mentees think are the most useful aspects of PFM mentoring?
a) __________________________________________________________
b) __________________________________________________________
c) __________________________________________________________
d) __________________________________________________________
process?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________

improved?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
VII. Assessment of PFM Capacity Enhancement Activities

PFM capacity in your woreda?
a) PFM Guidelines for PHC Very poor ☐ Poor ☐ Fair ☐ Good ☐ Very good ☐
b) PFM Mentoring Guidelines Very poor ☐ Poor ☐ Fair ☐ Good ☐ Very good ☐
c) PFM training Very poor ☐ Poor ☐ Fair ☐ Good ☐ Very good ☐
d) PFM mentoring Very poor ☐ Poor ☐ Fair ☐ Good ☐ Very good ☐
____________________________________________________________________
____________________________________________________________________
a) PFM Guidelines for PHC: _____________________________________________
__________________________________________________________________
b) PFM Mentoring Guidelines:___________________________________________
__________________________________________________________________
c) PFM training practices:_______________________________________________
__________________________________________________________________
d) PFM training materials: :______________________________________________
__________________________________________________________________
e) PFM mentoring: :____________________________________________________
__________________________________________________________________
VIII. PHC-Level PFM Practices and Performance

1. How do you assess the current planning and budgeting practices of PHCs in your woreda?
__________________________________________________________________

2. Rate PHCs’ planning and budgeting performance in your woreda over the last 1 to 2 years.
Tick only one:
a) Substantially improved ☐
b) Moderately improved ☐
c) Remained the same (no change was observed) ☐
d) Deteriorated ☐
e) Don’t know ☐
3. Which aspects of planning and budgeting have improved at PHCs over the last 1 to 2 years?
Tick all that apply.
a) Planning (evidence-based plan preparation, prioritization, and/or review) ☐
b) Budgeting (i.e., aligning plan with budget, revenue estimation, budget estimation,
budget submission and/or budget negotiation/defense) ☐
c) Financial transparency and accountability (i.e., transparency during budget

preparation, interaction between program and finance people, and/or roles of PHC
facility management and governing boards) ☐
d) None ☐
e) Please describe any specific improvements and/or comment on the magnitude of
the change(s):
____________________________________________________________________
____________________________________________________________________
4. Which aspects of cash flow management have improved at PHCs over the last 1 to 2 years?
a) Adherence to cash collection procedures ☐
b) Provision of credit services ☐
c) Petty cash management ☐
d) Depositing and bank accounts management procedures ☐
e) Payment processing and management ☐
f) None ☐
5. Which aspects of retained revenue management have improved at PHCs over the last 1 to 2
years? Tick all that apply.
a) Revenue source and amount projections, submission for appropriation ☐
b) Planning and use in line with the positive and negative list ☐
c) Timely utilization of retained revenue for approved purpose ☐
d) Auditing and reporting of retained revenue collection and use ☐
e) None ☐

6. Which aspects of accounts recording and reporting have improved at PHCs over the last 1 to
2 years? Tick all that apply.
a) Appropriate use of the chart of accounts ☐
b) Budget control including expenditure approval and/or use of budget/expenditure
subsidiary ledger card ☐
c) Accounting and recording procedures (i.e., use of right templates/forms, enforcing
lines of authority, preparation of monthly reconciliation statements, etc.) ☐
d) Reporting (i.e., completeness and accuracy of reports, use of appropriate recording
and reporting templates) ☐
e) None ☐
7. Which aspects of procurement have improved at PHCs over the last 1 to 2 years? Tick all
that apply.
a) Right quality of goods and services procured to fit the purpose(s) as per specifications ☐
b) Right quantity of goods and services procured ☐
c) Goods and services availed to the PHC level on time ☐
d) Goods and services procured with minimum costs, including acquisition and
operational costs ☐
e) None ☐
8. Which aspects of asset management have improved at PHCs over the last 1 to 2 years? Tick
all that apply.
a) Improvement in stock management (i.e., documentation using stock cards)☐
b) Periodic physical inventory of assets as per government standards ☐
c) Fixed assets management (i.e., receipt/issuance of asset tags, maintenance, etc.) ☐
d) Disposal of fixed asset (i.e., transfer, sales and scrap) ☐
e) Medical waste management and disposal ☐
f) Fixed asset inventory ☐
g) None ☐
9. How have internal controls at PHCs improved over the last 1 to 2 years? Tick all that apply.
a) Clarity to and adherence of internal control roles and authorities ☐
b) Having the required internal control structure and standards ☐
c) Periodic monitoring and correction on the internal control system ☐
d) Not at all ☐

10. How have auditing practices been improved and/or institutionalized at PHCs? Tick all that
apply.
a) Internal audit system in place and functional ☐
b) Each PHC in the woreda has been audited annually by an external auditor ☐
c) Most PHCs in the woreda received unqualified external audit reports ☐
d) Not at all ☐
IX. Overall Suggestions for Next Steps

level? _________________________________________________________________________
______________________________________________________________________________
2. In your opinion, what could the government do to improve PFM capacity enhancement supports
and practices at the PHC level? Please provide suggestions for the following government
institutions:
a) Federal level
i. MOH:_________________________________________________________
______________________________________________________________
ii. MOFEC:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
b) Regional level
i. BOFEC/BOFED:__________________________________________________
______________________________________________________________
ii. RHB:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
c) Zonal level
i. ZOFED:________________________________________________________
______________________________________________________________
ii. ZHD:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
d) Woreda level
i. WoFED:_______________________________________________________
______________________________________________________________

ii. WorHO:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________

Woreda Office of Finance and Economic Development Official 3

This key informant interview is to be used when conducting interviews with Woreda Finance and
Economic Development (WOFED) heads/representatives. Find the manager or the most senior person
responsible at this level. After greetings, introduce yourself and who you work for, and briefly explain
the purpose of the assessment/interview, the interview process including duration, and thank them
for seeing you.
any way.
assessment.”
Interviewee name (and providing oral consent):________________________________________
Interviewee position or title: _______________________________________________________
Interviewee qualification (type and level of education/certification):_______________________

________________________________________________________________________________
Region: _____________________________ Zone: ___________________________________
Name of WOFED: _________________________________________________________________
Interviewer signature (confirming consent): ____________________________________________
Interviewer contact number: __________________ Date of interview/consent: _______________

1. How long have you worked in the WOFED? _____________________________
Yes ☐ No ☐
1. Are you familiar with the PFM capacity enhancement support by the Transform: Primary Health
Care Project provides? Yes ☐ No ☐
f) At events where Transform: Primary Health Care introduced itself ☐
g) Other ☐ Specify: ____________________________________________

_____________________________________________________________
provided to the woreda and/or PHC facilities in the woreda? Tick all that apply.
g) Other ☐ Specify: ___________________________________________

Guide, PFM tools, and PFM training materials) have been provided to the WorHO and PHC
facilities in the woreda? Please list them:
a) ____________________________________________________________
b) ____________________________________________________________
c) ____________________________________________________________

d) ____________________________________________________________

__________________________________________________________________
Yes ☐ No ☐

____________________________________________________________________
____________________________________________________________________
IV. Rollout of PFM Training

1. Who were the trainees at the PFM rollout training sessions? Tick all that apply.
a) WOFED
i. Accountants ☐
iv. Other ☐ Specify: _______________________________________
b) WorHO
ii. Medical Service Coordinator/ Officer/ Process Owner ☐
iii. Other ☐ Specify: _______________________________________
ii. Accountant ☐
iv. Cashier ☐
vi. Internal auditor ☐

d) Health Centers
ii. Accountant ☐
iv. Cashier ☐
vii. Other ☐ Specify:________________________________________
e) Other ☐ Specify:___________________________________________
PHC level? _______%

a) __________________________________________________________
__________________________________________________________
b) __________________________________________________________
__________________________________________________________
b) PFM Guideline for PHC ☐
c) Pre- and post-training knowledge assessment tools ☐
e) Other ☐ Specify: __________________________________________
___________________________________________________________
f) Don’t know ☐
woredas in your woreda.

your woreda.
9. Do you have any suggestions for improving the quality of the training?
Yes ☐ No ☐

a) ___________________________________________________________
___________________________________________________________
b) ___________________________________________________________
___________________________________________________________
c) ___________________________________________________________
___________________________________________________________
V. Progress in Applying PFM Learning after PFM Training

Yes ☐ No ☐

c) Other ☐ Specify:_____________________________________________
____________________________________________________________
3. Based on information gathered during your visits to PHCs, do trained PFM staff from PHCs
have the same positions that they had when they attended the training?

4. If yes, approximately what percentage of them have the same position that they had when
trained? _________%
5. If no, what percentage are outside of the PFM system? ________%
6. Are trained PHC PFM staff promoted after receiving the training?
7. If yes, what percentage are still in a PHC-level PFM role but in a different position?
___________%

8. If yes, what percentage left or are no longer in the PHC PFM system? ___________%

10. If yes, rate the overall contribution of the PFM training in improving the PFM skills of staff
at the PHC level.
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
VI. PFM Mentoring

place?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
e) Don’t know ☐
Mentoring Guide?

Guide for PHC?
7. If no, why not? _____________________________________________________________
__________________________________________________________________________
above)?

__________________________________________________________________________
__________________________________________________________________________
components of PFM?
11. What do you believe mentees think are the most useful aspects of PFM mentoring?
a) __________________________________________________________
b) __________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
process?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________

improved?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
VII. Assessment of PFM Capacity Enhancement Activities

PFM capacity in your woreda?
those who receive it?

c) PFM training
d) PFM mentoring
____________________________________________________________________
____________________________________________________________________
a) PFM Guidelines for PHC: ______________________________________________
___________________________________________________________________
b) PFM Mentoring Guidelines:____________________________________________
___________________________________________________________________
c) PFM training practices:________________________________________________
___________________________________________________________________
d) PFM training materials:________________________________________________
___________________________________________________________________
e) PFM mentoring:______________________________________________________
___________________________________________________________________

VIII. PHC-Level PFM Practices and Performance
1. How do you assess the current planning and budgeting practices of PHCs in your woreda?
_________________________________________________________________________
_________________________________________________________________________
2. Rate PHCs’ planning and budgeting performance in your woreda over the last 1 to 2 years.
Tick only one:
d) Deteriorated ☐
e) Don’t know ☐
3. Which aspects of planning and budgeting have improved at PHCs over the last 1 to 2 years?

d) None ☐
the change(s):
____________________________________________________________________
____________________________________________________________________
4. Which aspects of cash flow management have improved at PHCs over the last 1 to 2 years?
f) None ☐

5. Which aspects of retained revenue management have improved at PHCs over the last 1 to 2
e) None ☐
6. Which aspects of accounts recording and reporting have improved at PHCs over the last 1 to
2 years? Tick all that apply.
e) None ☐
7. Which aspects of procurement have improved at PHCs over the last 1 to 2 years? Tick all
that apply.
e) None ☐
8. Which aspects of asset management have improved at PHCs over the last 1 to 2 years? Tick
all that apply.
a) Improvement in stock management (i.e., documentation using stock cards) ☐
g) None ☐

9. How have internal controls at PHCs improved over the last 1 to 2 years? Tick all that apply.
d) Not at all ☐
10. How have auditing practices been improved and/or institutionalized at PHCs? Tick all that
apply.
d) Not at all ☐
IX. Overall Suggestions for Next Steps

level? _________________________________________________________________________
______________________________________________________________________________
2. In your opinion, what could the government do to improve PFM capacity enhancement supports
and practices at the PHC level? Please provide suggestions for the following government
institutions:
a) Federal level
i. MOH:_________________________________________________________
______________________________________________________________
ii. MOFEC:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
b) Regional level
i. BOFEC/BOFED:__________________________________________________
______________________________________________________________
ii. RHB:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
c) Zonal level
i. ZOFED:________________________________________________________
______________________________________________________________

ii. ZHD:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
______________________________________________________________
d) Woreda level
i. WoFED:_______________________________________________________
______________________________________________________________
ii. WorHO:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________

Primary Hospital Official
Capacity and Practices at PHC Level

This key informant interview is to be used when conducting interviews with primary hospital
heads/representatives. Find the manager or the most senior person responsible at this level. After
greetings, introduce yourself and who you work for, and briefly explain the purpose of the
any way.
assessment.”
Interviewee name (and providing oral consent):_________________________________________
Interviewee position or title: ________________________________________________________
Interviewee qualification (type and level of education/certification):________________________

_________________________________________________________________________________
Region: _____________________________ Zone: ___________________________________
Name of hospital: _________________________________________________________________

1. How long have you worked in this primary hospital? ____________________________
2. How long have you worked in your current position? ___________________________
Yes ☐ No ☐
1. Are you familiar with the PFM capacity enhancement support that the Transform: Primary
Health Care Project provides? Yes ☐ No ☐

themselves ☐
g) Other ☐ Specify: ____________________________________________

_____________________________________________________________
provided to your hospital? Tick all that apply.
g) Other ☐ Specify: ___________________________________________
____________________________________________________________

Guide, PFM tools, and PFM training materials) have been provided to your hospital? Please
list them:
a) ____________________________________________________________
b) ____________________________________________________________
c) ____________________________________________________________
d) ____________________________________________________________

__________________________________________________________________
Yes ☐ No ☐

____________________________________________________________________
____________________________________________________________________
IV. PFM Training

1. Who at your hospital received PFM training? Tick all that apply.
a) Procurement, Finance, and Property Admin (PFPA) Process Owner ☐
b) Accountant ☐
c) Procurement Officer ☐
d) Cashier ☐
e) Property Admin. Officer ☐
f) Internal auditor ☐
g) Plan and Program Officer ☐
h) Other ☐ Specify: _______________________________________
i) Don’t know ☐
2. Were all of these trainees frontline PFM practitioners at your hospital?
your hospital? _______%

4. What training materials were used during the training?
e) Other ☐ Specify: __________________________________________
__________________________________________________________
f) Don’t know ☐
to-day PFM work in your hospital?
Yes ☐ No ☐
V. PFM Mentoring
place?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
e) Don’t know ☐
components of PFM?

5. What do you believe mentees in your hospital think are the most useful aspects of PFM
mentoring?
a) __________________________________________________________
b) __________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
process?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
improved?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
VI. Assessment of PFM Capacity Enhancement Activities

1. How effective is the PFM capacity enhancement support provided by the Transform: Primary
Health Care Project (through guidelines, tools, training, and mentoring) in improving PFM
capacity in your hospital?

c) PFM training
d) PFM mentoring
____________________________________________________________________
____________________________________________________________________

VII. PFM Practices and Performance
1. How do you assess the current planning and budgeting practices at your hospital?
_____________________________________________________________________________
_____________________________________________________________________________
2. Rate the planning and budgeting performance in your hospital over the last 1 to 2 years. Tick
only one:
d) Deteriorated ☐
e) Don’t know ☐
3. Which aspects of planning and budgeting have improved at your hospital over the last 1 to 2

d) None ☐
the change(s):
____________________________________________________________________
____________________________________________________________________
4. Which aspects of cash flow management have improved at your hospital over the last 1 to 2
f) None ☐

5. Which aspects of retained revenue management have improved at your hospital over the last
1 to 2 years? Tick all that apply.
e) None ☐
6. Which aspects of accounts recording and reporting have improved at your hospital over the
last 1 to 2 years? Tick all that apply.
e) None ☐
7. Which aspects of procurement have improved at your hospital over the last 1 to 2 years? Tick
all that apply.
a) Right quality of goods and services procured to fit the purpose(s) as per specifications
☐
e) None ☐
8. Which aspects of asset management have improved at your hospital over the last 1 to 2
g) None ☐

9. How have internal controls improved at your hospital over the last 1 to 2 years? Tick all that
apply.
d) Not at all ☐
10. How have auditing practices been improved and/or institutionalized at your hospital? Tick all
that apply.
d) Not at all ☐
VIII. Overall Suggestions for Next Steps

delivery of its PFM training, mentoring, and other capacity enhancement activities at your
hospital? _____________________________________________________________________
_____________________________________________________________________________
government institutions:
a) Federal level
i. MOH:_________________________________________________________
______________________________________________________________
ii. MOFEC:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
b) Regional level
i. BOFEC/BOFED:__________________________________________________
______________________________________________________________
ii. RHB:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
c) Zonal level
i. ZOFED:________________________________________________________
______________________________________________________________

ii. ZHD:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
d) Woreda level
i. WoFED:_______________________________________________________
______________________________________________________________
ii. WorHO:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
______________________________________________________________
ii. Other:_________________________________________________________
______________________________________________________________

Primary Hospital Finance and Administration Official

This key informant interview is to be used when conducting interviews with primary hospital finance
and administration heads/representatives. Find the manager or the most senior person responsible at
this level. After greetings, introduce yourself and who you work for, and briefly explain the purpose of
the assessment/interview, the interview process including duration, and thank them for seeing you.
any way.
assessment.”

_________________________________________________________________________________
Region: _____________________________ Zone: ___________________________________
Name of hospital: _________________________________________________________________

1. How long have you worked in this primary hospital? ____________________________
2. How long have you worked in your current position? ___________________________
Yes ☐ No ☐

themselves ☐
g) Other ☐ Specify: ___________________________________________________

____________________________________________________________________
provided to your hospital? Tick all that apply.
g) Other ☐ Specify: ___________________________________________

Guide, PFM tools, and PFM training materials) have been provided to your hospital? Please
list them:
a) ____________________________________________________________
b) ____________________________________________________________
c) ____________________________________________________________
d) ____________________________________________________________

3. If no, please specify the reason:___________________________________________________
_____________________________________________________________________________
Yes ☐ No ☐

____________________________________________________________________
____________________________________________________________________
IV. PFM Training

1. Who at your hospital received PFM training? Tick all that apply.
b) Accountant ☐
d) Cashier ☐
f) Internal auditor ☐
g) Plan and Program Officer ☐
h) Other ☐ Specify: _______________________________________
i) Don’t know ☐
2. Were all of these trainees frontline PFM practitioners at your hospital?
your hospital? _______%

e) Other ☐ Specify: __________________________________________
__________________________________________________________
f) Don’t know ☐
to-day PFM work in your hospital?
Yes ☐ No ☐
V. PFM Mentoring
place?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
e) Don’t know ☐
components of PFM?

5. What do you believe mentees in your hospital think are the most useful aspects of PFM
mentoring?
a) __________________________________________________________
b) __________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
process?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
improved?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________

your hospital?

c) PFM training
d) PFM mentoring
____________________________________________________________________
____________________________________________________________________

1. How do you assess the current planning and budgeting practices at your hospital?
_____________________________________________________________________
_____________________________________________________________________________
2. Rate the planning and budgeting performance in your hospital over the last 1 to 2 years. Tick
only one:
d) Deteriorated ☐
e) Don’t know ☐
3. Which aspects of planning and budgeting have improved at your hospital over the last 1 to 2

d) None ☐
the change(s): ________________________________________________________
4. Which aspects of cash flow management have improved at your hospital over the last 1 to 2
f) None ☐
5. Which aspects of retained revenue management have improved at your hospital over the last
1 to 2 years? Tick all that apply.
e) None ☐

6. Which aspects of accounts recording and reporting have improved at your hospital over the
last 1 to 2 years? Tick all that apply.
e) None ☐
7. Which aspects of procurement have improved at your hospital over the last 1 to 2 years? Tick
all that apply.
e) None ☐
8. Which aspects of asset management have improved at your hospital over the last 1 to 2
g) None ☐
9. How have internal controls improved at your hospital over the last 1 to 2 years? Tick all that
apply.
d) Not at all ☐

10. How have auditing practices been improved and/or institutionalized at your hospital? Tick all
that apply.
d) Not at all ☐

delivery of its PFM training, mentoring, and other capacity enhancement activities in your
hospital? _________________________________________________________________
_________________________________________________________________________
a) Federal level
i. MOH:_________________________________________________________
______________________________________________________________
ii. MOFEC:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
b) Regional level
i. BOFEC/BOFED:__________________________________________________
______________________________________________________________
ii. RHB:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
c) Zonal level
i. ZOFED:________________________________________________________
______________________________________________________________
ii. ZHD:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
d) Woreda level

i. WoFED:_______________________________________________________
______________________________________________________________
ii. WorHO:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
______________________________________________________________
ii. Other:_________________________________________________________
______________________________________________________________

TOOL 7
Key Informant Interview Questionnaire
Health Center Official

This key informant interview is to be used when conducting interviews with health center
heads/representatives. Find the manager or the most senior person responsible at this level. After
greetings, introduce yourself and who you work for, and briefly explain the purpose of the
“The purpose of this assessment is to gather data on public financial management (PFM) capacities and
practices at the PHC level and Transform: Primary Health Care Project PFM capacity enhancement
efforts so that the contributions of these efforts to improving PFM at the primary health care (PHC) level
can be assessed. If there are questions for which someone else is the most appropriate person to provide
that information, I would appreciate it if you could introduce me to that person. Any information you
provide as part of this interview will be kept confidential. Any reference to the information you provide
in our analysis will be made without mentioning or implicating your name in any way.
assessment.”

_________________________________________________________________________________
Region: _____________________________ Zone: ___________________________________
Name of health center: _____________________________________________________________
Interviewer name: _________________________________________________________________
Interviewer signature (confirming consent): _____________________________________________
Interviewer contact number: __________________ Date of interview/consent: ________________

1. How long have you worked in the health center? ____________________________
2. How long have you worked in your current position? _________________________
Yes ☐ No ☐
II. Knowledge about Transform: Primary Health Care Project – PFM Capacity Enhancement Work
b) A project PFM specialist had informed me ☐

themselves ☐
g) Other ☐ Specify: ___________________________________________________

____________________________________________________________________
provided to your health center? Tick all that apply.
g) Other ☐ Specify: ___________________________________________
____________________________________________________________

Guide, PFM tools, and PFM training materials) have been provided to your health center?
Please list them:
a) ____________________________________________________________
b) ____________________________________________________________
c) ____________________________________________________________
d) ____________________________________________________________

3. If no, please specify the reason:__________________________________________
__________________________________________________________________

Yes ☐ No ☐

_____________________________________________________________
_____________________________________________________________
IV. PFM Training

1. Who at your health center received PFM training? Tick all that apply.
b) Accountant ☐
d) Cashier ☐
f) Internal Auditor ☐
g) Other ☐ Specify:________________________________________
h) Don’t know ☐
2. Were all of these trainees frontline PFM practitioners at your health center?
your health center? _______%

e) Other ☐ Specify: __________________________________________
______________________________________________________________
to-day PFM work in your health center?
Yes ☐ No ☐
V. PFM Mentoring
1. Has PFM mentoring been provided to PFM practitioners at your health center?
place?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
e) Don’t know ☐
components of PFM?
5. What do you believe are the most useful aspects of PFM mentoring for you and your team?
a) __________________________________________________________
b) __________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________

process?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________
improved?
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________
d) ___________________________________________________________

your health center?
those who receive it?

c) PFM training
d) PFM mentoring
____________________________________________________________________
____________________________________________________________________

1. How do you assess the current planning and budgeting practices at your health center?
_____________________________________________________________________________
_____________________________________________________________________________
2. Rate the planning and budgeting performance in your health center over the last 1 to 2 years.
Tick only one:
d) Deteriorated ☐
e) Don’t know ☐
3. Which aspects of planning and budgeting have improved at your health center over the last 1
to 2 years? Tick all that apply.

d) None ☐
the change(s): _______________________________________________________
___________________________________________________________________
4. Which aspects of cash flow management have improved at your health center over the last 1
to 2 years? Tick all that apply.
f) None ☐
5. Which aspects of retained revenue management have improved at your health center over
the last 1 to 2 years? Tick all that apply.
e) None ☐

6. Which aspects of accounts recording and reporting have improved at your health center over
the last 1 to 2 years? Tick all that apply.
e) None ☐
7. Which aspects of procurement have improved at your health center over the last 1 to 2 years?
a) Right quality of goods and services procured to fit the purpose(s) as per specifications
☐
e) None ☐
8. Which aspects of asset management have improved at your health center over the last 1 to 2
g) None ☐
9. How have internal controls improved at your health center over the last 1 to 2 years? Tick all
that apply.
d) Not at all ☐

10. How have auditing practices been improved and/or institutionalized at your health center?
b) Each HC in the woreda has been audited annually by an external auditor ☐
c) Most HCs in the woreda received unqualified external audit reports ☐
d) Not at all ☐

delivery of its PFM training, mentoring, and other capacity enhancement activities at the
health center level? __________________________________________________
___________________________________________________________________
a) Federal level
i. MOH:_________________________________________________________
______________________________________________________________
ii. MOFEC:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
b) Regional level
i. BOFEC/BOFED:__________________________________________________
______________________________________________________________
ii. RHB:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
c) Zonal level
i. ZOFED:________________________________________________________
______________________________________________________________
ii. ZHD:__________________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________

d) Woreda level
i. WoFED:_______________________________________________________
______________________________________________________________
ii. WorHO:_______________________________________________________
______________________________________________________________
iii. Other:_________________________________________________________
______________________________________________________________
i. Health Centers:_________________________________________________
______________________________________________________________
ii. Other:_________________________________________________________
______________________________________________________________

Usaid Transform - Primary Health Care Project - Public Financial Management Enhancement

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USAID TRANSFORM:

PRIMARY HEALTH CARE PROJECT

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | i

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | ii

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | iii

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | iv

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | v

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 1

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 2

2.1 Project Capacity Enhancement Support

4 At the time of the assessment.

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 3

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 4

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 5

Aug. 2018 Dec. 2018 July 2019 Oct. 2020

Nov. 2018 Mar. 2019 June 2020

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 6

2016/17 2017/18 2018/19 2019/20

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 7

2016/17 2017/18 2018/19 2019/20

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 8

Visited 2017/18 2018/19 2019/20

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 9

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 10

4.2 Study Settings

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 11

4.3 Study Design and Instruments

4.4 Limitation of the Assessment

4.5 Data Analysis

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 12

Average Average Years Percent of Managers/

5.1 Knowledge about Project’s PFM Capacity-enhancement Work

5.2 Usefulness of PFM Capacity-enhancement Materials

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 13

5.3 Training of PFM Trainers/Master Trainers

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 14

5.4 Rollout of PFM Training

5.5 Progress in Applying PFM Learning after PFM Training

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 15

5.6 PFM Mentoring Practices

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 16

5.7 Assessment of Current PFM Practices and Performances

5.8 Institutionalization and Sustainability of Project Support on PFM

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 17

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 18

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 19

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 20

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 21

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 22

Transform: Primary Health Care Project

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 23

The following major questions will be covered under the assessment:

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 24

5. Data collection, compilation, analysis, and duration

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 25

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 26

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 27

INSTRUCTIONS FOR INTERVIEWER

PUBLIC FINANCIAL MANAGEMENT ENHANCEMENT ASSESSMENT REPORT | 28

Region: _ Zone: ______

Interviewer contact number: ____ Date of interview/consent: _