System-level health emergency preparedness in Ethiopia: insights from senior healthcare decision-makers triangulated with documentary analysis

Introduction A wide range of epidemiological, environmental, and security-related emergencies pose challenges to the Ethiopian health system. However, there is limited research on the country’s system-level preparedness for these emergencies. Particularly, the progress of system-strengthening efforts and the readiness of the country’s health system remain unclear. Therefore, this study adopts a systems approach to examine health emergency preparedness across tiers of Ethiopia’s health system. Method The study employed a reflexive thematic analysis, triangulated with document analysis. Data collection involved in-depth interviews with 27 healthcare decision-makers across the health system tiers. Eight out of 27 participants were selected from the top tier of the health system (three from the Ministry of Health, three from the Ethiopian Public Health Institute, and two from the National Emergency Medical Team). The next 7 participants were interviewed from the middle layer of the health system, specifically the Public Health Emergency Management divisions of regional health offices. The other 5 participants were selected from the country’s major hospitals (front-line). The remaining 7 participants were selected from domestic and international non-governmental organisations. In-depth interviews were conducted face-to-face (18 participants), by phone (2 participants), and virtually via Teams (7 participants). Participants were recruited using a combination of purposive and snowball sampling techniques, which stopped once data saturation was achieved. Saturation was considered reached when additional interviews generated no substantively new codes, themes, or insights relevant to the research question. The interview data were analysed using a reflexive thematic analysis approach. The analysis involved a series of iterative steps, including familiarisation with the data, coding, developing initial themes, and reviewing, refining, and defining the themes. The emerging themes and sub-themes were further polished through reviews of eleven relevant policy documents, strategic plans, guidelines, and external assessment reports. Document analysis was guided by interview-derived themes as a deductive framework, in which the convergence, divergence, and silence between participants’ insights and documentary evidence were examined. Results The inductive analysis of interview data revealed two themes. The first theme, “System Strengthening Effort: Achievements and Ongoing Challenges,” provides both positive progress and ongoing challenges in strengthening health system preparedness. Noted successes include the expansion of healthcare infrastructure, the development of healthcare task forces, and improvements in organisational structure. In contrast, key challenges in health system preparedness include policy implementation, disconnects in healthcare infrastructure, inadequate cascading of achievements to the grassroots, and a lack of sustainability in preparedness efforts. The second emerging theme was “Mixed Perceptions: Optimism, Caution, and Uncertainty Regarding Readiness Level. “This theme comprises participants’ perceptions of the country’s health system readiness. The two themes complement each other, as the structural achievements and challenges identified in the first theme provide the context for participants’ mixed perceptions in the second theme. Similarly, document review reveals that Ethiopia has achieved substantial strategic and structural progress in health emergency preparedness, despite uneven implementation, varying operational capacities across health system levels, and a lack of sustainability, all of which continue to constrain progress in preparedness. Conclusion Ethiopia has made strategic and structural progress in health emergency preparedness, but these gains have not consistently translated into operational readiness across health-system levels. Gaps in implementation, integration, grassroots capacity, and sustainability remain. Preparedness initiatives should therefore prioritise translating policies and structural investments into integrated and sustainable operational capacity across health-system levels. Future research should evaluate the extent to which these efforts strengthen and sustain operational readiness across different health-system levels.