Delphi R1 — Strategy Dashboard

Governance and leadership are constrained by fragmented authority across levels, limited clarity in decision-making mandates, and centralized control that delays timely response. Coordination across sectors is inconsistent, and accountability mechanisms are not uniformly enforced. Emergency governance structures are not fully institutionalized within routine system functions, resulting in reactive rather than sustained preparedness.

The Public Health Emergency Management system, including emergency operations centers and incident management structures, has demonstrated the ability to coordinate responses during outbreaks. Rapid response mechanisms and integrated surveillance approaches have supported timely detection and field-level action. Existing coordination platforms have shown capacity to mobilize multisectoral actors during crises.

Coordination and communication are affected by fragmented structures, parallel reporting systems, and limited integration across sectors. Weak alignment between national and subnational levels contributes to inconsistencies in response and delays in decision-making.

Leadership during emergencies requires the ability to make timely decisions, coordinate across sectors, manage uncertainty, and communicate effectively. Systems thinking and responsiveness to rapidly changing conditions are central competencies. Specially, our leaders lacks how to manage and work with different stakeholders. They do not oversee the stakeholders interest, level of influence and how to deal with them.

Establish Clear and Pre-Delegated Decision Authority Institutionalize a Unified Command System at All Levels Strengthen Functional Multisectoral Coordination Empower Woreda and PHC Levels with Resources and Tools Build Leadership and Management Capacity at Subnational Levels Strengthen Real-Time Data Use for Local Decisions

National Incident Management Framework with Local Adaptation Tiered Trigger System (“Escalation–De-escalation Protocols”) Delegated Authority with Guardrails Integrated Emergency Operations Centers (EOCs) Network Standardized Data Architecture with Local Dashboards Joint Planning with Flexible Microplanning Flexible Financing with Accountability Multisectoral Coordination with Defined Roles

Improving coordination and communication in Ethiopia’s health system is less about adding new meetings and more about fixing how information, authority, and accountability flow both vertically (across levels) and horizontally (across sectors):- * Redesign Vertical Coordination (National → Region → Woreda → PHC) * Strengthen Horizontal (Multisectoral) Coordination * Integrate Communication Systems and Tools

Public Health Proclamation No. 200/2000 Why it matters: This is the primary legal framework governing disease prevention and control in Ethiopia. Gaps Outdated relative to modern threats (pandemics, climate-sensitive outbreaks, AMR). Limited clarity on multi-sectoral coordination and accountability. Weak provisions on data sharing, digital surveillance, and risk communication. 2. Public Health Emergency Management (PHEM) Guidelines (EPHI) Why it matters: Operational backbone for surveillance, preparedness, and response. Gaps Guidelines are not legally binding, limiting enforcement. Variable implementation across regions. Weak institutionalization of Incident Management System (IMS). 3. Ethiopian Public Health Institute (EPHI) Regulation No. 301/2013 Why it matters: Defines EPHI’s mandate to lead PHEM and implement International Health Regulations (IHR). Gaps Limited authority to enforce compliance across sectors. Coordination power is more technical than regulatory.

The main weaknesses in governance and leadership include 1. Decisions, including how, when, and what resources to use during public health emergencies, depend primarily on political factors, where evidence-based decision-making and scientific facts often have less value compared to political feasibility. 2. Weak legal and mandate framework – the lack of strong legal frameworks that guide the clear responsibilities of all agencies outside of health to act during public health emergencies 3. Ineffective multi-sectoral coordination – there is difficulty in bringing all sectors together prior to emergencies and currently coordination is usually ad hoc. 4. lack of accountability – leadership focus is more reactive than proactive due to lack of accountability mechanisms in place.

1) a digital system to allow health facilities to report directly to the federal level 2. Adopt the 7-1-7 metric (7 days to detect, 1 day to notify, 7 days to respond) as a performance KPI for every leadership tier. 3. Unified Incident Management Systems (IMS) will help ensure that non-health sectors (like the Disaster Risk Management Commission, animal health, and environmental health) are trained on the same IMS protocols used by the health sector. 4. Trigger-based contingency budget support for woreda level

1. Digital Interoperability 2. Standardized Incident Communication 3. Horizontal & Multi-Sectoral Flow with one health sector

Public Health Proclamation The Issue: This directive is the primary legal tool for health regulation but does not account for modern challenges like digital data privacy or cross-border health security (IHR 2005). Revision Needed: Include legal protections for digital surveillance data to ensure real-time reporting, and it should also be used for non-health surveillance, which would build multi-sectoral coordination, community trust and system participation.

1. Adaptive and Agile Leadership 2. Technical and Systems Competency 3. Collaborative and Multisectoral Diplomacy 4. Communication and Trust Building 5. Ethical and Equitable Stewardship

To foster a resilient, multi-sectoral health system, the "Harmonization and Alignment" framework is moving away from fragmented, donor-driven projects toward a "One Plan, One Budget, One Report" model where every partner, from a local NGO to the World Bank, plugs into the national strategy.

Institutionalize Intra-Action Reviews (IARs) during prolonged emergencies (like droughts or 6-month outbreaks). Conduct Multi-Sectoral Joint Operations Reviews Create a National Health Security Knowledge Repository Use Simulation Exercises (SimEx) to test if the lessons from the last AAR were absorbed.

1. Integrated Coordination Platforms 2. Multi-Sectoral Resilience Frameworks through one health platform 3. Public-Private Partnership Governance

The major weakness includes: 1. Limited Leadership and Governance Capacity. Many assigned personnel lack adequate training and experience in leadership, governance, and emergency management. This skills gap reduces the system’s ability to make timely, coordinated, and strategic decisions during public‑health emergencies. 2. Weak One Health Coordination and Multisectoral Collaboration. Although a One Health platform has been formally established, effective multisectoral coordination and collaboration remain limited. Operational linkages between human, animal, and environmental health sectors are still weak, reducing the country’s ability to detect and respond to complex, multisectoral threats. 3. Delayed Approval and Endorsement of Emergency Preparedness and Response Plans. EPRPs are often endorsed late or not endorsed at all hindering timely resource mobilization, delaying strategic decision‑making, and reducing overall preparedness. 4. Insufficient Sub‑national Engagement and Limited Enforcement at Regional Levels. Due to Ethiopia’s federal structure, regional autonomy sometimes leads to inconsistent implementation of national directives. Weak accountability mechanisms and limited engagement with sub‑national structures reduce harmonization of emergency management efforts across regions. 5. Inadequate Use of the Incident Management System (IMS). The IMS is not consistently applied in accordance with the Public Health Emergency Operations Center (PHEOC) handbook. During emergencies, leadership redundancies at the Ministry of Health (MoH) and EPHI, along with insufficient empowerment of the Incident Manager, create confusion and undermine efficient response coordination. 6. Poor and Fragmented Health Information Systems. Fragmented data systems and limited interoperability hinder rapid analysis, information sharing, and evidence‑based decision‑making. This weakens situational awareness and slows timely response during emergencies.

Decentralized governance can be significantly enhanced through the following strategic actions, ensuring that regions, zones, and woredas including PHC facilities are empowered to respond quickly and effectively during public‑health emergencies: 1. Build Leadership and Governance Capacity at Sub‑national Levels. Strengthen the competencies of regional, zonal, and woreda health leaders through continuous training in leadership, governance, emergency management, and decision‑making. 2. Establish and Fully Functionalize Public Health Emergency Operations Centers (PHEOCs) at Sub‑national Levels. Ensure each region and zone has a functional PHEOC with clear structures, roles, and operational capacity to coordinate preparedness and response. 3. Provide Continuous Incident Management System (IMS) Training. Institutionalize routine IMS training for sub‑national teams to improve clarity of command, emergency coordination, and rapid response capability. 4. Establish and Operationalize One Health Coordination Mechanisms at Sub-national Levels. Strengthen multisectoral collaboration by ensuring that One Health platforms are functional at sub-national levels, enabling coordinated action across human, animal, and environmental health sectors. 5. Enhance Experience Sharing and Documentation of Good Practices. Promote peer‑learning forums, cross‑regional exchanges, and systematic documentation of lessons learned to accelerate adaptive learning across the health system. 6. Support the Development and Endorsement of Sub‑national Emergency Preparedness and Response Plans (EPRPs). Facilitate timely development, approval, and implementation of context‑specific EPRPs, backed by predictable and flexible financing mechanisms. 7. Strengthen Digital and Interoperable Information Systems at Sub‑national Levels. Expand digitized surveillance, reporting, and data‑sharing systems to ensure real‑time information flow, interoperability, and evidence‑based decision‑making.

The following changes can improve vertical and horizontal coordination: 1. Implementation of unified IMS structure 2. Enhancing One Health mechanisms at all levels 3. Digitization of information systems 4. Establishing formalized communication and coordination forums 5. Harmonization of preparedness and response plans with predictable financing

In my point of view the major weaknesses in governance and leadership that limit Ethiopia's health system adaptability and resilience to prepare for, respond to, and recover from public-health emergencies are 1.There is inconsistent PHEM structures across regions. Some regions (Tigray, Dire Dawa etc.) are still operating under health bureau or research institute causing resource duplication, effort overlap, poor integration of surveillance, response, recovery functions, and unclear roles/authority. Those coordination gaps also delay lab confirmations, sample transport, and outbreak notifications. 2. In most of the outbreaks leadership commitment and attention doesn’t go beyond the acute phase causing sharp declines in capacities. As a result, leaders usually struggle to institutionalize the strategies applied during the emergency into routine health care system or sustain monitoring and follow-up. 3. Because funding is always short leaders are forced into reactive, budget-driven prioritization during overlapping crises. This often results in short-term, survival-oriented choices that undermine long-term adaptability and resilience 4. The national PHEM framework has strong policy mandates for After-Action Reviews and Intra-Action Reviews but in practice high-level and especially mid-level leaders conduct them inconsistently (only for select major events, not routinely across all emergencies). In addition, lessons learned are rarely translated into sustained changes in routine primary health care, planning, or budgeting. This creates a cycle where the system forgets lessons between crises, capacities erode quickly, and adaptability remains limited. 5. The health governance is highly vulnerable to political instability. Ongoing conflicts cause both direct destruction and governance breakdown, forcing leaders at all levels to shift their focus to security. This erodes health priorities, fragments authority, and leaves the system reactive rather than resilient. 6. Emergencies are frequently framed and initially managed as health-sector only issues under EPHI/MoH leadership, with full whole-of-government (multisectoral) platforms activated only after the crisis escalates. This delay prevents timely integration of non-health sectors (agriculture, WASH, environment, education, finance, security, NDRMC) whose contributions are essential for root-cause mitigation, resource mobilization, and cross-border management. 7. Weak capacity at the mid-level leadership specifically at regional health bureaus (RHBs), zonal/sub-city, and woreda/district PHEM departments and managers. EPHI explicitly describe it as the weakest link and an inverted pyramid (robust federal capacity with under-resourced structures below). This directly undermines timely local risk assessment, response scaling and sustaining gains post-emergency. 8. Poor data sharing between regions

1. Enforce uniform, minimum-standard PHEM structures at regional, zonal, woreda, and health facility levels 2. Targeted mid-level leadership capacity building 3. Strengthen sub-national multisectoral platforms 4. leverage ePHEM digitization for local autonomy and decision making 5. Mandate every emergency (even small outbreaks) triggers a woreda-level AAR/IAR and integrate the results into annual PHC packages, HEW training, and indicators.

1. Activate and formalize the interministerial Joint Coordination Committee / National Public Health Security Council (promised at the NAPHS launch) with the Prime Minister or Deputy Prime Minister as chair 2. Include NAPHS key indicators in federal and regional performance 3. Leverage high-visibility events and recognition mechanisms

- The Ethiopian Public Health Institute has taken up the role of the PHEM with a coordinated structure within the institution, and the PHEOCs established both at the national and subnational levels - Leadership capacity building on emergency management, decision-making and multisectoral coordination.

- Crisis management; adaptive leadership, communication, multisectoral collaboration; evidence-based decision making

Strengthen Multi-Level (Vertical) Communication Systems Enhance Cross-Sector (Horizontal) Coordination Mechanisms

Establish a National Public Health Emergency Council or steering committee with legally mandated authority, independent of political cycles. Define clear roles and responsibilities for national, regional, and PHC levels in law or regulation. Ensure cross-sector membership (health, finance, security, local government) to maintain continuity.

Key weaknesses include centralized decision-making that limits rapid local action, weak coordination across sectors and administrative levels, and inconsistent implementation of policies across regions. In addition, limited accountability mechanisms and unclear role delineation during emergencies reduce responsiveness and adaptability.

The establishment of Public Health Emergency Operations Centers (PHEOCs) and national multi-sectoral task forces has demonstrated strong coordination and timely decision-making during emergencies such as COVID-19. These structures should be institutionalized and expanded to subnational levels with clear mandates and sustainable resources.

Strengthening coordination requires formalizing communication channels across national, regional, and PHC levels, supported by interoperable digital platforms. Regular joint planning, simulation exercises, and integrated reporting systems can improve alignment across sectors.

Empower local authorities as decision-makers, not just implementers, by ensuring they have clear mandates, timely access to data, and adequate financial and human resources. This should be supported by strong accountability mechanisms, effective multi-sectoral coordination, and a unified command structure that aligns local actions with national emergency response systems.

Institutionalize formal, system-wide coordination and communication mechanisms, moving beyond ad hoc, crisis-driven approaches. This should include clear coordination structures, shared data systems, and joint accountability frameworks that link national, regional, district, and PHC levels, while strengthening multi-sectoral collaboration.

On the public health side, there is usually quick turnover of leadership, meaning initiatives started by one leader may not be carried on or prioritized when the next person comes in. While there is some strategic planning that happens (HSTP and now HSDHIP, 3-5 year strategic plans), how participatory these planning processes are nor how seriously/what priority these can be questioned - often new initiatives and individual leaders priorities tend to be given more oversight. The capacity to prevent, detect, and respond to public health emergencies requires collaboration within departments, across agencies, and across sectors. Governance remains a key barrier to this. The absence of or limitations in existing legal frameworks play a role, including mandate ambiguities between MOH and EPHI on issues of One Health/multi-sectoral coordination, data repository, and outbreak response play a role. As far as I know, a lot of the leadership capacity building is concentrated at national and in some cases at regional levels. With regional public health institutes now becoming more common, strong leaders are also needed at lower levels, and more investment and tailored public health leadership capacity building would be beneficial.

Across sectors consensus is needed on areas of collaboration, including on data sharing, joint investigation and response. The collaboration should be driven by mutual understanding and mostly a win-win solution for all. Vertically the focus should be on strengthening sub-national capacity so that EPHI does not need to respond to every emergency. More decentralized fund disbursement (along with accountability), having regions lead capacity efforts including cascading trainings to zones/woredas/facilities.

MOUs exist between multi-sectoral entities for collaboration, stronger legal mandate is needed to drive this collaboration EPHI regulation and MOH health services proclamation - there appears to be some ambiguity around roles and responsibilities when it comes to data management (where it looks like both are responsible for warehousing health and health related data) Gov't public procurement policy: Although it allows for direct purchasing during emergencies, it does not define what qualifies as "emergency", leaving this up to decision makers Person data protection law - Will create difficulties when it comes sharing relevant public health data, including cross-border data sharing as this law now requires approval from other government agencies before data can be shared

Strong public health institutional base: Institutions like EPHI and PHEM structures have shown capacity in surveillance, coordination, and outbreak response. Emergency Operations Centers (EOCs): Activation of EOCs during crises has improved coordination and information flow—this model should be further institutionalized at all levels. Multi-sectoral coordination platforms: Task forces and technical working groups have enabled cross-sector collaboration and should be formalized with clear mandates. Experience from COVID-19 response: Rapid mobilization of resources, guidelines, and workforce demonstrated the system’s ability to adapt under pressure. Decentralized service delivery platforms: The health extension program and woreda-level structures provide a strong foundation for community-based response. Digital health and surveillance improvements: Expansion of DHIS2 and other digital tools has enhanced reporting and can be leveraged for real-time decision-making. Partner coordination mechanisms: Platforms for donor and partner alignment (e.g., joint reviews, pooled funding discussions) can be strengthened and sustained. Adaptive leadership practices: In crisis periods, some leaders demonstrated flexibility and innovation—these practices should be captured and embedded into leadership development programs.

redefine clear delegated authorities for regions, zones, woredas, and PHC facilities during emergencies (e.g., procurement thresholds, resource reallocation, activation of response teams). Develop pre-approved emergency protocols and SOPs to reduce delays in approvals from the federal level. Ensure alignment of mandates across health and non-health sectors to avoid duplication or gaps. Create emergency contingency funds at regional and woreda levels with clear utilization guidelines. Allow flexible budget reprogramming during emergencies without lengthy approval processes. Strengthen financial accountability systems to ensure transparency alongside flexibility.

Clarify roles, mandates, and reporting lines Define who leads, who supports, and who decides at each level during routine operations and emergencies. Harmonize mandates across national, regional, and local structures to reduce duplication and gaps. Establish clear reporting and feedback channels with standard timelines. Institutionalize multi-level coordination platforms Establish regular, structured coordination forums linking national–regional–district–PHC teams (e.g., weekly or biweekly reviews). Strengthen multi-sectoral platforms (health, finance, education, WASH, agriculture, etc.) with clear terms of reference. Ensure these platforms are functional beyond emergencies, not ad hoc.

Disaster Risk Management (DRM) policy and legal framework Gaps: Coordination between health and broader DRM structures is not fully institutionalized Roles across sectors can be unclear during health emergencies Needed changes: Clarify health sector leadership within multi-hazard emergencies Strengthen multi-sectoral coordination mandates and enforcement Align DRM and PHEM structures for seamless activation and coordination.

Institutionalize coordination and governance platforms Maintain standing multi-sectoral coordination bodies for health security and emergency management. Ensure continuity of national and regional coordination committees with legal mandates. Document and standardize meeting structures, reporting formats, and decision protocols.

the routine surveillance and reporting systems that can be adapted during emergencies. The other is the multi-sectoral One Health coordination mechanism can also be institutionalized and be scaled-up at regional level

To institutionalize innovation, it's critical to strengthen knowledge management systems across sectors/institutions for documentation and sharing of best practices

THE multi-disciplinary task forces that pulled experts from health, economy, environment, and Local community

emplacing Strategic Risk Communication, Cross-Sector Coordination Platforms

multisectoral coordination and local resource availability

well trained multisectoral task forces, community -based surveillance and local resource pool