 This research found that the Primary Health Care Transformation Initiative, PTI, in Ethiopia had positive effects on district health office and health center management capacity. The PTI also showed improvements in health systems performance such as ANC coverage, contraceptive use, skilled birth attendance, and infant immunizations. However, the PTI did not have a significant effect on overall health systems performance as measured by the KPIs summary score. This suggests that additional strategies may need to be implemented to further improve health systems performance. This article was authored by Lingrui Liu, Mayur M. Desai, Netsanet 15, and others.