Background: Evidence suggests that primary health care managers (PHCU) operate in an increasingly complex health environment that is characterized by epidemiological, economic, social, demographic, political, and technological change in the midst of rising consumer expectations. The skill set and competencies that health managers are required to have in order to perform satisfactorily within this environment are vastly different from what they were a decade ago. In particular, woreda/district level health managers need to have deeper and broader leadership, management, and governance practices to meet the evolving challenges of their jobs. However, little is known about the magnitude of leadership practices among front-line health care managers in low income countries like Ethiopia.

Objective: To assess the magnitude of leadership practices and associated factors among primary health care managers in selected areas of Eastern Ethiopia

Methods: Institutional based cross-sectional study design supplemented with qualitative inquiry was used from February 01 to 28, 2018. Ethical clearance was secured from Haramaya University Institutional Health Research Ethics Review Committee.  Four hundred and sixty nine randomly selected study participants participated in the quantitative study. Facilitators’ guided self-administered questionnaires were used to collect the quantitative data. The collected data were entered onto Epi-Data version 3.1.1 and exported to Stata v. 14.2 computer software for analysis. The degree of association between outcome variable of interest (leadership practice) and the corresponding independent variables was assessed using bivariable binary logistic regression analyses. Variables with p value of < 0.2 during bivariable analyses were entered into multivariable logistic regression model to control for all possible confounders and to identify independent predictors of outcome variable. Odds ratio along with 95% confidence interval were estimated to measure the strength of the association. Level of statistical significance was declared at p-value < 0.05. For the qualitative data collection, 20 purposively selected senior health care providers working in health facility were interviewed using an in-depth interview. Qualitative data were transcribed verbatim and analyzed using thematic analysis.

Results: The magnitude of good leadership practices was [47.97%, 95%CI: (43.47, 52.52)]. In multivariable logistic regression analysis, the odds of good leadership practice were nearly 2.4 times [(AOR= 2.35, 95%CI: (1.27, 4.37)], 1.7 times [(AOR= 1.71, 95%CI: (1.04, 2.81)], and 2.7 times [(AOR=2.65, 95%CI: (1.32, 5.32)] higher among midwives, nurses, and other professional categories respectively. The odds were also 1.6 times [(AOR= 1.61, 95%CI:  (1.06, 2.43)] higher among PHCU managers who had experience sharing with their equivalent managers working in other facility. Moreover, results of an in-depth interview with senior health care providers indicated that PHCU managers lack at most appropriate decision making, time management, and financial management skills among leadership practices. Senior health care providers also replied that their managers are doing the same thing from time to time by simply duplicating the existing approach or walking on the existing road without looking for innovative ideas to improve the performance of their organization to the desired level. The majority (60%) of the senior health care providers themselves did not take any form of leadership training.

Conclusion: The magnitude of leadership observed among the study population in the study area was found to be moderate.  Leadership practices were independently associated with professional category and experience sharing with equivalent managers working in other facility. Most of the health care providers also mentioned that PHCU managers lack some important leadership practices s which might have affected their organization’s performances. Thus, human resource managers at next higher levels and all relevant stakes need to arrange profession specific in-service training and strengthen experience sharing activities of the primary health care unit managers to scale –up their leadership practices in study area in particular and in Ethiopia in general.

Key words: Leadership, Management, Governance, Primary Health Care Unit, Skills, Practices