BACKGROUND:
Community participation and engagement is a fundamental component of the PHC approach. Currently, Ethiopia has started implementing a 15-year Health Extension Program (HEP), known as HEP optimization Roadmap that intends to realize the contribution of the HEP in the delivery of more comprehensive and better quality PHC services close to the community. Understanding the actual resource implications, the processes, and implementation outcomes is critical to facilitate learning and inform the scale-up.

METHODS:
A concurrent mixed-methods study design was used. A cross-sectional survey, and a qualitative individual and group interviews were undertaken. A multi-stage sampling technique with simple random sampling and random selections were used to include participants from the project sites. We adapted the Practical Robust Implementation Sustainability Model (PRISM) that builds on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework considering a developmental evaluation approach. Quantitative and qualitative data were collected, analyzed and triangulated.

RESULTS:
The national level performance of implementing the strategy was 49.4%, while 86.7% in project sites. A total of 376 VHLs were recruited in the project site, of those only 70.8% were functional. Average number of households (HHs) visited by a VHL per month was 35.0. Multiple revised CE strategies making VHL at the center were implemented. The design stage of VHL was managed systematically to optimize, facilitate acceptance and collaboration. Almost all of the VHLs (>90%) fulfills the recommended selection criteria. Most of the VHLs (60%-80%) reported they received training on relevant topics. About 88% of VHLs are reporting on their activities. The cost drivers were identified and it was feasible. The PHC staff accepted and adopted the strategy.

CONCLUSIONS:
The reach of VHLs as a community engagement strategy was modest to optimize the HEP efforts, and the national scale-up efforts should be continued.