Opportunities and lessons from the COVID-19 pandemic: a qualitative study of health program managers’ perspectives in Ethiopia

Abstract

Introduction

Globally, the COVID-19 pandemic has created opportunities to enhance accessibility and strengthen health system beyond the immediate response to the crisis. Irrespective of its impact on human life and the economy, COVID-19 has contributed to some healthcare improvements. Therefore, this study aimed to explore the experiences and perspectives of health programs managers regarding the opportunities and lessons learned following the COVID-19 pandemic in Ethiopia.

Methods

A phenomenological qualitative study design was employed focusing on experts working in different programs and departments in the Ministry of Health. Key Informant Interviews (KII) were done from March 28 to April 22, 2023 among fourteen purposively selected participants from all essential programs coordinated at MoH. Data were managed and analyzed with the assistance of NVivo version 14.0 to code transcripts and compare the coding within-group and between-group responses and themes.

Results

Two main themes are discussed, opportunities that emerged and lessons learned following the pandemic of COVID-19. Opportunities include advancement in innovation and health technology for health care, improved infectious disease control mechanisms, improved prevention of Neglected Tropical Diseases (NTD), online training for healthcare providers, prompt and prolonged drug refills for chronic illnesses, behavioural change practices to the adoption of disease preventive measures like hand hygiene, social distancing and mask use practices, and integration of COVID-19 response into routine care. Lessons learned include ensuring the continued provision of other health services, the need for community awareness to better manage health crises, and the role of emergency preparedness as important facets for managing and guarding against future pandemics.

Conclusions

The COVID-19 pandemic has contributed to the prevention of other infections, time saving through online platform which prevents further travel, and innovation for health services. Sustaining health care services under the emergency, allocating funds for emergencies, strengthening emergency preparedness and building a resilient health system that can withstand natural and man-made emergency problems were among lesson learned from the pandemic time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14483-5.

Background

The COVID-19 pandemic has significantly disrupted global economic activities and livelihoods [1]. It is evident that COVID-19 has negatively impacted over 200 countries and millions of individuals globally [2]. Nevertheless, the global crisis has also provided opportunities to enhance accessibility and health security on a broader scale [3]. The COVID-19 pandemic has catalysed a wave of inspiring innovations in healthcare globally [2]. Furthermore, the recommended COVID-19 preventive measures, such as handwashing and the use of sanitizers, have fostered behavior change, resulting inhabitual actions that extend beyond the immediate responses to the pandemic [4].

Prior to the pandemic, innovations within healthcare were impeded by various factors, including a lack of funding, the regulatory approval processes for innovation, administrative procedures, ethical considerations, clinical trial testing, and conflicts among stakeholders such as insurers, medical device companies, pharmaceutical corporations, hospitals, clinicians, and researchers [2]. The pandemic has also exposed the fragility of health systems and economies in several countries, revealing their inadequacy in combating a significant health crisis [5].

Innovations in healthcare during the pandemic became feasible as individuals and organizations collaborated to solve the existing challenges from both the private and public sectors [2]. The progressive realization of universal health coverage needs effective governance and integration with social protection systems [6]. Until the occurrence of the COVID-19 pandemic, the capacities of health sectors were poorly understood. However, the pandemic exposed the resilience of health system, and has prompted a shift in the mindset of policymakers, leading to realization of the necessity for increased investment in the health sector [3].

COVID-19 has underscored that access to healthcare for all is not optional. A stable, equitable, prosperous, and peaceful society is essential, and economic growth is only feasible when no one is left behind [3]. While, there was a marked decline in in-person visits for care during othe COVID-19 pandemic, there was also a corresponding increase in virtual care, allowing patients with chronic diseases to return to pre-pandemic visit rates [7]. This in turn, resulted in the utilization of limited resources, further supplemented by resource sharing among the government and the private sector [8]. It also led to notable innovations such as virtual care, home-based care, advancements in diagnosis and therapy, virtual learning, and virtual clinical education for regulators, academic medical centers, faculty, and students [9].

Technologies such as digital health records are instrumental in providing healthcare providers with access to accurate, up-to-date, and comprehensive information about patients, thereby facilitating more coordinated care throughout a patient’s entire care journey [10]. Despite its profound impact on human life and the economy, COVID-19 has contributed to advancing universal health coverage within the context of health-related Sustainable Development Goals (SDG) [3]. Technological innovations in healthcare are for both reducing costs and improving patient outcomes [10].

The COVID-19 pandemic has imparted significant lessons on how to respond to medical and public health emergencies, which will be applicable to individuals, families, nations, and the global community [3]. Increasing knowledge, shifting mindsets, and altering human behavior are considered the most critical strategies for implementing healthcare innovations to address the pandemic and other health challenges [2]. Many countries’ health systems were characterized by limited capacity and underfunding, with inadequate and ineffective equipment, a shortage of often unprotected healthcare workers, and a generally fragile healthcare infrastructure [5]. This serves as a clear indication that health systems in numerous countries must evaluate and prepare for any upcoming public health emergencies.

COVID-19 has posed significant challenges to lives, health system, economies, and every aspect of global society. Following a substantial loss of life and a severe economic impact, there has been a process of coping and adaptation to the pandemic. Several innovative strategies were employed during the pandemic to mitigate the crisis. However, there is limited information on how to capitalize on the innovations and technological advances made during the pandemic to address ongoing challenges. Therefore, this study aims to explore health managers’ experiences and perspectives regarding health-related opportunities and lessons learned following the COVID-19 pandemic.

Research questions:

1. What are the opportunities that come to Ethiopian health care following the COVID-19 pandemic?

2. What are the lessons that the Ethiopian Health care system can learn from the COVID-19 pandemic for better future pandemic containment?

Methods

Study design

A qualitative study was conducted between March 28 and April 22, 2023 employing phenomenology approach to elicit information from purposively selected experts working at the Ethiopian Ministry of Health who had experience both during and before the COVID-19 pandemic. Respondents were selected from 14 essential programs of the MoH.

Study area

This study was conducted at the Ethiopia Ministry of Health including Maternal Health, Child Health, Reproductive Health (RH), Tuberculosis (TB), Malaria, Non-communicable Diseases (NCD), Neglected Tropical Diseases (NTD), Human Immunodeficiency Virus (HIV), Nutrition, Mental Health, One Wash and Environmental Health, Expanded Programs of Immunizations (EPI), and Gender-based Violence (GBV). The ministry of Health is the leading organization for ensuring a healthy nation across the country from 12 regions and two city administrations, as this data is nationally representative. With a high population of about 123 million people (2022), Ethiopia is the second most populous nation in Africa after Nigeria and one of the fastest-growing economies in the region, with an estimated 6.4% growth in FY2021/22. However, it also remains one of the poorest, with a per capita gross national income of $1,020. Ethiopia aims to reach lower-middle-income status by 2025. Ethiopia’s real Gross Domestic Product (GDP) growth slowed down from FY2019/20 to FY2021/22 due to multiple shocks, including COVID-19, with growth in industry and services easing to single digits. However, agriculture, where over 70% of the population is employed, was not significantly affected by the COVID-19 pandemic, and its contribution to growth slightly improved compared to previous years [11].

Sampling technique and study participants’ selections

Fourteen [14] respondents from essential programs were purposively selected, based on their unique experience, expertise, and participation in decision-making, monitoring, and oversight activities during the COVID-19 pandemic. They had an in-depth understanding of the phenomena and were able to give detailed information on the nature of problems, experiences on how to manage the challenges, and what opportunities and lessons they have witnessed during and aftermath of the pandemic [12, 13]. We considered previous long working experience in the sector, their education preparation, leadership experience and practical participation in routine healthcare services as selection criteria. Accordingly, the minimum educational level selected was masters’ holders and medical doctors were included. A minimum of two years was considered for experience to capture experience before and during the pandemic, history of active participation of participant during the pandemic and minimum of master’s degree/ MD were recruited. A formal support letter requesting the participation of selected respondents was shared with them and a suitable time and date for the interview were communicated by the respondents. Accordingly, all participants were informed and the interviews were undertaken in a separate room with no additional sound.

Data collection procedures

The data were collected through Key Informant Interviews (KII). Interviews were facilitated by AAT and GF in a quiet and private room selected by KII interviewers at Ethiopian MoH following standard procedures for qualitative studies [12–14]. All KII participants were given study information, and written informed consent was obtained before the commencement of the interview. The interviews were undertaken face to face by trained qualitative researchers who were part of the study team (AAT and GF). The interview guide was prepared in English and translated into Amharic and Afan Oromoo based on the preference of the respondents after reviewing relevant literature [13–16]. The interviews were recorded on an audio device to increase the reliability of the data collected. The interviews lasted 45 min on average. Interviewers with ample experience in qualitative research conducted the interviews. Then, the audio recorded were transcribed by the interviewers themselves. Data saturation point was determined based on evaluation of the interview topic guides, where the interviewers (AAT and GF) sequentially evaluated each interview session one-by-one and identify a point on which no new information was found. Accordingly, no new information was emerged after the 12th interview, although additional two interviews have been conducted to further ensure the saturation of data.

Data management and analysis

All audio files were transcribed verbatim in English by two team members of the study (AAT and GF). Quality control was ensured by other team member (JB) by proofreading the transcripts against their respective audio recording to ensure reliability of the data. Transcripts were imported into NVivo version 14 software for coding. Inductive approach was employed. A 5% of the transcripts were first readline-by-line by two of the authors (GF, and AAT), to develop codebook. And then, this codebook was shared and discussed among the team members for mutual understanding. This codebook was used as a reference and framework to conduct team-based coding. These themes and sub-themes were organized following the specific research questions.

The actual coding was undertaken by two skilled and experienced members (AAT and GF) and the coded data was merged together. Meanwhile, issues which cannot be included in the initial codebook we documented separately and considered in data presentation and analysis. The data analysis process involved exporting nodes and sub-nodes to a word document, reading all quotes in each sub-node to develop similarities and differences, pattern development, and selecting illustrative quotations for each emergent theme. Queries were performed to compare the coding against nodes and attributes to compare and contrast within-group and between-group responses and themes.

Results

Participant characteristics

Three out of 14 KII participants were female, majority of them held masters’ degree holders and two of participants were medical doctors; they had served in their respective departments represented for an average time of 6.7 years with a minimum experience of 2 years to more than ten years. The age of participants ranges in between 30 and 45 years (Table 1).

Table 1.

Demographic characteristics of study participants, Addis Ababa, Ethiopia, 2023

S. no	Program	Sex	Experience	Educational status
1.	Non-communicable Disease (NCD)	Male	2 years with the unit	MPH
2.	Mental Health	Male	3 years	MPH
3.	NTD	Male	12 years	MPH
4.	Maternal Health	Female	5 years	MD
5.	Malaria	Male	10 years	MPH
6.	Child Health	Male	7 years	MD, MPH
7.	EPI	Female	4 years	MPH
8.	TB	Male	15years	MD, MPH
9.	HIV	Male	11 years	MPH
10.	Nutrition	Male	7 years	MPH
11.	Women’s and Child affairs (GBV)	Female	5 years	MPH
12.	Environmental Health	Male	4 years	Msc
13.	One WASH	Male	4 years	Msc
14.	SRH (Sexual and Reproductive health)	Male	10 years	MD

We identified two themes as summarized in Table 2 and four sub-themes. These are opportunities that emerged and lessons learned following the pandemic of COVID-19. Opportunities include advancement in innovation and health technology, support from private partners, and behavioral change, while lessons learned include efforts to sustain service and preparedness for future pandemics (Table 2).

Table 2.

Opportunities and lessons learned following the COVID-19 pandemic in Ethiopia,2023

Theme/Sub theme	Sub theme	Description	Codes	Sample quotes
Health system Opportunities following COVID-19 pandemic	Health innovation	It to describe health innovations (including: innovations in medical equipment like mechanical ventilators, face masks, pedal opening handwashing facilities, sanitizer, and other supplies that were required for pandemic response that were more than the usual response), time and resource management (virtual platforms to orient as well as to provide on-the-job capacity-building activities), Integration of COVID-19 with other health services (screening the community for non-communicable diseases at the time of house-to-house awareness creation for COVID-19 in addition to those services provided at health facilities),	• Increased access to critical medical supplies. • Integration of COVID-19 with other health services • capacity-building approaches for Health workers (virtual approaches)	“……. As we remember, there was a shortage of oxygen during the pandemic. It is another issue. The country has played an exemplary role in the case of medical oxygen, like giving training, and planting an oxygen plant was there with the support of those donor partners. I think it was the impact of COVID as a benefit. There was oxygen storage at an early phase, training, distribution, and implantation of a new oxygen plant, and it was also the reason for funds from donors. These are at least the advantages of the COVID-19 pandemic.” ETH-KII-child health-3-04
	Support from private partners	Resource mobilization and collaboration (Support system established from private organization for pandemic response)	• Logistic support to respond to the pandemic	“…The way we engage non-governmental organizations is one of the best practices that can also be used for other diseases. Multi-support we have to take as best practice and use for the priority that we have got from the COVID.” ETH-KII-NTD-3-03
	Behavioral change	Is to describe the change in practice of handwashing, and avoidance of public recommendation like avoidance of handshaking.	• Adoption of hand hygiene (WASH) practices Adaptation of other disease preventive behaviors	“Yes, it creates anything a man can believe, for example, handwashing. We have developed a hand-washing road map after COVID-19. Higher officials’ and experts’ perception of hand washing for infection was changed completely. …. ….” ETH-KII-MOH_Wash and Envi Health.
Lesson learned for future pandemic control	Efforts to sustain service, and preparedness	This to describe health care activity related with ensuring continued provision of other health services, creating awareness in communities, allocating funds for emergencies, strengthening emergency preparedness and building a health system that can withstand natural and man-made emergency problems.	• The need for continued service provision • Community awareness should continue • Emergency preparedness is key	“From this, the lesson we can take is to build a health system that can withstand natural and man-made emergency problems. Surveillance programs that exist in EPHI have to be there…. In addition, finance, human power, and a fast strategy that is ready for implementation have been there. One of the errors during COVID was the regions were expected to prepare their response plans. But there should be a ready response mechanism to fit the emergencies.” ETH -KII-child health

Opportunities that emerged from COVID-19

Opportunities that existed during the COVID-19 pandemic in Ethiopia were observed through health innovations, time and resource management, and resource mobilization and collaboration as discussed from the respondents’ perspectives below;

Health innovations

Under this sub-theme, all health care service provision systems, equipment, and strategies to create resilient health care during the pandemic will be illustrated. Accordingly, study participants had reported that there were creations and innovations in medical equipment like mechanical ventilators, face masks, pedal opening handwashing facilities, sanitizer, and other supplies that were required for pandemic response that were more than the usual response. There was a panic condition at the beginning that interrupted the provision of routine health care services; however, it was possible to integrate COVID-19 with other health services like screening the community for non-communicable diseases at the time of house-to-house awareness creation for COVID-19 in addition to those services provided at health facilities. One significant opportunity that was capitalized on at the time of the pandemic was the utilization of virtual platforms to orient as well as to provide on-the-job capacity-building activities.

Increased access to critical medical supplies

The majority of the participants stated that the pandemic was a catalyst for the transformation of healthcare services, particularly evident in the adaptation and optimization of resources such as oxygen and other medical supplies, despite their scarcity. This adaptation has led to a notable enhancement in emergency response capabilities within the country through capacity building and creating avenues for sustainability through extensive tree-planting projects. This showcases a commendable evolution in the resilience and efficacy of healthcare systems.

……. As we remember there was a shortage of oxygen during the pandemic. It is another issue. The country has played an exemplary role in the case of medical oxygen like giving training, and planting oxygen plant was there with the support of those donor partners. I think it was the impact of COVID as a benefit. There was Oxygen storage at an early phase, training, distribution, and implantation of new oxygen plant and it was also the reason for funds from donors. These are at least the advantages of the COVID-19 pandemic ETHKII-child health-3-04.

In another way, participants have described that accessibility of diagnostic services was advanced following the pandemic. This can be supported by a quote from a participant as follows:

Technologies have been changing rapidly; at first COVID samples were sent to South Africa, and we will wait until the result comes. This exacerbates the condition of the pandemic. But now rapid test kits are at any facility, and it is one of the advantages of COVID. Standby systems have to be there for new diseases and new variants. ETH-KII-child health-3-04

The participant also described the changes in capacity building for handling these emergency medical supplies in addition to following the pandemic. Here the quote taken from participant:

When we developed the oxygen roadmap in 2016, there were plans for an oxygen plant, oxygen cylinders, and oxygen storage. As we remember, there was a shortage of oxygen during the pandemic. It is another issue. The country has played an exemplary role in the case of medical oxygen, like giving training, and planting oxygen trees was there with the support of those donor partners. I think it was the impact of COVID as a benefit. There was oxygen storage at an early phase, training, distribution, and implanting new oxygen trees, and it was also the reason for funds from donors. These are at least the advantages of the COVID-19 pandemic. ETH-KII-child health-3-04

Overall, current study participants explained that the pandemic has created an opportunity to expand the disease’s diagnostic capacity and avail of important medical supplies like oxygen machines. This implies that the pandemic can be taken for increasing accessibility of life-saving medical supplies like oxygen machines and diagnostic services for PCR machines within Ethiopia.

Integration of COVID-19 with other health services

Guidelines were establishment for the integration of COVID-19 services into routine care through COVID screening at all health service delivery points. Furthermore, innovative measures facilitated prompt prescription refills for individuals managing chronic conditions, thereby enhancing the timely accessibility of medications for multiple ailments. This was through ensuring adequate drug supply to prolong the duration for the next refill which contributed to better time management and reduced exposure to COVID-19.

One of the respondents stated “We recommended multi-month dispensing of drugs. We did prolong of follow-up period. Besides, we recommend further screening and diagnostic work-up if suspected of COVID-19. Based on the TB program, other services such as malaria, HIV, and noncommunicable diseases, essential service guidelines were released.” ETH-KII-TB-3- 01.

There was another quote describing the importance of integrating COVID-19 with other care.

Yes, for example, we have tried to integrate with GBV response exactly. We have a 5-year strategic plan every 5 years in each region. Additionally, expansion was done in collaboration with the emergency team. Like any other population, women have the full right to get another service, as one activity was impossible, as it was locked. ETH-KII-MOH-GBV-3-13

The panic condition occurred at early-phase COVID-19 and has affected certain program services. However, experience from MOH of Ethiopia indicated the importance of advocacy for sustaining essential programs at the time of a pandemic through advocacy options. This can be supported by the following quote from a participant:

At different times there were advocacy activities in addition to mitigation. We have used higher officials for discussion; it was one of the mitigation strategies on sustaining essential health services by preparing messages. ETH MOH-03-EPI

There was also great move in availing the drugs for patients with chronic diseases than their previous existence after making especial discussion with Ethiopian Drug Authority. This can be supported by one male KII part working as expert for NCD as follows:

The first and major thing was making drugs available as these drugs are taken for life long, whether it is diabetes mellitus, hypertension or Cancer. We have made the drugs for these diseases accessible at health facilities by communicating with the Ethiopian Drug Authority. After making drugs available we made appointment spacing for drugs taken monthly as they cannot come during that time even after two months. Therefore, we made it at least every three months if possible six months that will enable them to take their drug without interruption. ETH-03-NCD

Efforts of health extension workers have made efforts to integrate their routine services with COVID-19. This can be supported the following quote

……During home-to-home distribution of drugs, health workers were simultaneously screening suspected cases of covid based on their symptom presentation. Sustainability of the service needs research. We strongly recommend handwashing not only for COVID prevention but also for NTD. ETH-KII-MOH-NTD

Participants emphasized that there were efforts and success in integrating healthcare services for patients in need at the time of COVID emergency care, screening other chronic diseases, and availing multi-month drugs for patients with known chronic medical conditions. This implies that there must be due attention for other health care needs of the community beyond the pandemic care to minimize and overcome life loss that can occur from other causes at time of crisis.

Innovative capacity-building approaches for Health workers

COVID-19 led to innovative working modalities, like virtual meetings and remote working. These focused on ensuring that health workers were updated and trained to prevent and manage COVID-19 cases despite the need for social distancing.

Zoom meetings significantly minimized costs. A negative side of online meetings is the low quality of activities when compared to face-to-face activities. ETH-KII-SRH

Another participant also described the issue as follows:

There were efforts to avoid services through media so normal people will stay at home, and normal people with the sign will be taken to a health facility to give a sample and report to the health facility. The gathering was replaced with virtual activities, like online, using digital methods. For example, you will gather people to give a brief on guidelines previously. It replaced the virtual system that was manipulated due to the COVID pandemic. ETH MOH-03: Environmental Health and One Wash

The result from the current study indicated that the utilization of online Zoom meeting platforms and remote working/medical care for patients was both resource-effective and important for timely responding to the need. It can be taken as an opportunity to reduce movement-related contact risk for overcoming pandemics like COVID-19.

Increased private sector engagement

There were a huge public-private partnership and engagement in pandemic response including donating their own houses, and hotels for treatment and quarantine centres was among the major contribution followed the pandemic. This can be elaborated by quote from KII participants as follows:

…The way we engage non-governmental organizations is one of the best practices that can also be used for other diseases. Multi-support we have to take as best practice and use for the priority that we have got from the COVID. ETH-KII-NTD-3-03

Private organizations, including the media, have highly contributed to pandemic control, which should have to be upgraded for future consumption. This can be supported quote by quote from one KII participant as follows:

….Not only government but also society contributed a lot. Private owners were also supporting activities. These should be appreciated. Media activities were encouraging and supportive. Some people provide their house, hotels others donate soap, etc. So, to strengthen health system, public-private partnership is very important and we should learn from the pandemic era…. ETH-KII-NTD-3-03

Another KII participant also decreased the importance of private sector participation for mobilizing resources as well as improving the medical supplies at the time of emergencies. This can be supported by the following quote:

Coping with the pandemic and intensive mobilization, making the service providers rethink about the condition, improving supply shortage as much as possible…. ETH-MOH-KII-Nutrition-3-08

The study participants emphasized that the efforts of private-public partnership were important at the time of the pandemic to overcome challenges related to scarcity of resources and improving the supply chain of medical supplies. The Ethiopian experience of private sector engagement for overcoming pandemic care through committing the house for treatment centers and residence of professionals enables the government to overcome challenges of resources at the time of emergency.

Community behavioral change

Adoption of hand hygiene (WASH) practices

Participants mentioned that hand sanitation improved with an increase in handwashing practices and use of sanitizers. It became a norm to access hand sanitation points at different public sites as well as increased individual conscience on hand hygiene when compared to the times before the pandemic.

Lung diseases like pneumonia, common cold, and influenza were decreased as reports were indicating. Therefore, things like covering noses with arms/hands are still there during sneezing. Generally, there are impacts on technologies we can take after COVID. ETH-KII-child health-3-04

Besides the practice of handwashing, there were efforts for sustaining the practice of handwashing at the national level, as the Ethiopian government made for handwashing following COVID-19. This can be described by the following quote from a participant.

Yes, it creates anything a man can believe, for example, handwashing. We have developed a hand-washing road map after COVID-19. Higher officials’ and experts’ perception of hand washing for infection was changed completely. …. …. ETH-KII-MOH_Wash and EnviHealth

Another participant also elaborated the practice as follows:

Both government and non-government have to do all WASH within all facilities (Water facility, Hygiene facility). Because disease has a relation to hand washing recommendations, sanitation facilities, menstrual hygiene have to be within the health facility. Sanitation facilities have to exist with a patient ratio. Whenever any pandemic comes, there should be human resources with all cadres from nurses to specialty. ETH- KII-child health-3-04

Participants emphasized that consistent community adherences to recommended preventive practice like handwashing have resulted to secondary advantage age of decreasing upper respiratory tract infection, NTD, and other diseases that can be prevented by appropriate hand hygiene. The result implies that proper handwashing is an effective preventive method for sustainable disease prevention and control when community engagement is assured.

Adaptation of other disease preventive behaviors

They noted that masks continue to be used among people in their community, which contributes to disease prevention among users. Other disease preventive measures include observation of social distance and body contact, which they shared to contribute to the prevention of other communicable diseases.

Still, we are using masks. Still, populations with comorbidity conditions have to use mask. I think it is there still. Things like kissing/hugging, is gradually coming but when we look at the COVID peak time of March 2020 it is not comparable with 2023. Therefore, things like covering noses with arms/hands are still there during sneezing. The pandemic had also contributed to decrement of upper respiratory tract infection.… Lung diseases like pneumonia, common cold, and influenza were decreased as reports indicated. ETH-KII-child health-3-04.

Other lesson achieved through the COVID-19 was the prevention of control of NTD which were related with personal hygiene and water availability like trachoma. This implies that sustainable effort can assure prevention of disease even under emergency condition. This can be supported by the following quote

Community education and campaigns about covid-19 preventive measures are also important to prevent transmission of neglected tropical diseases. It was a good experience, and we learned a lot. There are water and soap everywhere, including schools and institutions. If water is available, students wash their hands and face, which prevents transmission of trachoma. It created a good opportunity to wash their hand. So, we learn a lot from the experience of covid-19 and work accordingly. So, there are good things that are introduced as a result of the pandemic…… ETH-KII-MOH-NTD

Another participant has also described the importance of COVID-19 practices like masks for the prevention and control of other infectious diseases of the upper respiratory tract, like influenza. This quote can support the ideas as follows:

Yes, of course. I am not infected by the influenza virus after a habit of wearing a face mask. There is an epidemic of influenza. So, wearing face masks protected us a lot. This is my personal experience. My friends share similar experiences. ETH-KII-MOH-NTD

Participants emphasized that consistent community adherence to recommended preventive practices like handwashing has resulted in the secondary advantage of decreasing upper respiratory tract infections, NTDs, and other diseases that can be prevented by appropriate hand hygiene. The result implies that proper handwashing is an effective preventive method for sustainable disease prevention and control when community engagement is assured.

Lesson learned for future pandemic control

The COVID-19 pandemic provided lessons that can be referred to in Ethiopia and across the globe in case of future pandemics. Key lessons learnt include ensuring continued provision of other health services, creating awareness in communities, allocating funds for emergencies, strengthening emergency preparedness and building a health system that can withstand natural and man-made emergency problems. These are important to guard against and respond to future pandemics. Respondents felt that the lessons from COVID-19 prepared them to manage future pandemics.

The need for continued service provision

The health system should be resilient enough with other routine services in addition to emergency response, as the impact from other non-emergency diseases is significantly important. This can be supplemented by the below quote from one KII participant as follows:

Anyway, the pandemic may be one disease that can have a large effect. But there are also other diseases like infectious diseases (TB, HIV) and NCD. Because these diseases do not stop as the pandemic comes. Therefore, we have to think as such. ETH − 03-NCD

In order to ensure the continuation of certain essential services even during the ongoing pandemic, the Ethiopian Ministry of Health implemented national initiatives. The following statement from a study participant lends credence to this:

………To overcome this issue, the Ministry of Health has prepared guidelines that I have told you earlier to sustain other routine health services like institutional delivery, child immunization, and those mothers’ seeking surgery, like using all media that I have told you earlier. It becomes possible to sustain facilities gradually. ETH MOH-03-Child Health

Other participants have described that the service provision was guided by the national documents following the pandemic for the successful sustaining of the service for some essential programmes like the Expanded Programme of Immunisations (EPI). This can be elaborated on by the following as follows:

We have taken mitigation strategies by preparing documents in which all essential services will be sustained in all regions. there was an impact in the first 3 months. ETH MOH-03-EPI

There was an introduction of unusual service provision modalities and follow-up mechanisms for the patients with chronic diseases. Those were introduced at the time of the COVID-19 pandemic in Ethiopian healthcare, like multi-month drug provisions and follow-ups.

We prepared a guideline on how to continue providing TB treatment services by considering home-based treatments and transportation issues and what if the drug is discontinued. We already prepared an interim guideline. By the time it was announced as a pandemic, we prepared interim guidelines and sent them to the regions. Clients were not expected to go to a health facility to get drugs. So, drugs were given or prescribed for 1 to 2 months. We recommended multi-month dispensing of drugs. We did prolong of follow-up time period. Besides, we recommend further screening and diagnostic work-up if suspected of covid-19. ETH-KII- MOH-TB-3- 01

Another participant has also described the importance of sustaining sexual and reproductive health services as follows:

We developed a guideline about how to sustain the existing service while fighting the COVID pandemic. A decreased service in the first 3 to 6 months of the pandemic period was resumed. ETH-KII-MoH_SRH_3–10

The care of chronic disease was sustained through prolonged refill time for patients taking their medication, like patients with mental health, NTD, and other NCD. This reveals that flexibility of health care facilities and professionals enables better control of disease processes at times of emergency. This can be supported by the following quote:

The majority were declined. First, for any disease, the drugs were made to be given for a prolonged period of time. For example, as drugs were continuous, those given for a month were given for three months. Even more than this, prolonged appointments were made. ETH MOH-03-Mental health

Another participant has explained the Ethiopian government’s re-initiation of service provision and sustaining services provision under public health emergency for chronic diseases like TB, DM, and HIV. Here is the quote as follows:

At the beginning, there was a fear of a decreased number of people utilizing health care services. There was a temporary disruption of service. There are clients with chronic illnesses who discontinued their medication, such as diabetic patients, HIV patients, and TB patients. Patients with acute illnesses such as fever and diarrhea are scared to visit the facility at the beginning. After a few months, the government reorganized the health service and communicated clearly with mass media to encourage health care service utilization. Providers were also informed to serve incoming clients. Then, it was restored. ETH-MOH-KII-HIV-3-05

Other participants also described the importance of national efforts to sustain care of chronic diseases like TB. It was possible because of commitment existing at the Ethiopian Ministry of Health. This can be elaborated by the following quotes:

………. TB program is sustainable because guideline developed at federal level implemented in health center as it is because there are focal persons in each tier. We do not assign a new health professional for screening covid-19 among TB patients because there is already assigned TB focal person who can manage it. ETH-KII- MOH-TB-3- 01

Overall, the finding from the current study disclosed that the Ethiopian Ministry of Health has introduced new strategies and methods that enable them to sustain other diseases’ care and treatments. Chronic disease care and follow-up were assured through multi-month drug provision, online follow-ups, and endorsing different national services sustaining guidelines like those for TB. It implies that the routine services provisions are not optional at the time of emergency through strategies that minimize the risk of exposure to emergency conditions.

Community awareness

Creating awareness and engaging the community are very crucial lessons that can be derived from the COVID-19 response. The role of leadership was core for awareness creation to community so than restoration for basic health services care was possible. This can be supported by one KII quote as stated below.

At different times there were advocacy activities in addition to mitigation. We have used higher officials for discussion; it was one of the mitigation strategies on sustaining essential health services by preparing messages. ETH MOH-03-EPI

The current study explored importance of community awareness and engagement during pandemic which can be achieved through awareness creation and other efforts.

We should have to continue with early alerting and activating people. Community engagement starting from the early onset is also very critical and important. ETH-03- GBV

The house-to-house visit for pandemic control and awareness creation creates an opportunity for informing the community regarding other diseases in addition to COVID-19. This can be supported by the following quote:

Apart from this, at the Addis Ababa Health Bureau, house-to-house case detection was done by the family healthcare team. Capacity-building activities, monitoring, supporting reports, and two times per week regarding COVID activity evaluation. There were strategies to re-establish the discontinued services. ETH MOH-03-Child Health

Close monitoring of the pandemic control activities and awareness creation and updated information by leadership were crucial for properly implementing prevention and control at the community level. This can be supported by one of the following quotes:

I think a big role is a message of (= your Excellency minister Dr. Lia, ministry of health=). The Ethiopian public health institute is also a forefront by daily update; sharing of covid-19 related information and data to the society. I think this a great education until introduction of vaccine. ETH-KII- MOH-TB-3- 01

Emergency preparedness is key

Participants elaborated that the importance of emergency preparedness with human, financial, and system-level resources was very important. Further, there should be a standby response mechanism for the emergency that can arise from man-made as well as natural public health emergencies. This can be further supported by a quote from one of the KII participants as follows:

From this, the lesson we can take is to build a health system that can withstand natural and man-made emergency problems. Surveillance programs that exist in EPHI have to be there…. In addition, finance, human power, and a fast strategy that is ready for implementation have been there. One of the errors during COVID was the regions were expected to prepare their response plan. But there should be a ready response mechanism to fit the emergencies. ETH -KII-child health-3-04

A significant lesson learned from COVID-19 is the need to increase medical emergency equipment and prepare for future emergencies. There was a limited number of oxygen machines in the nation before the pandemic, including emergency treatment centers. However, the pandemic teaches the Ethiopian health system well.

When we look at the oxygen supply for medical services supply before COVID and after COVID there is a huge difference. ETH MOH-03-Child Health

Discussion

Interpretation of findings

The study explored the opportunities that the COVID-19 pandemic brought to the healthcare system based on health programs managers’ perspectives using a qualitative study design approach. It highlights the lessons and insights gained following the pandemic. Our study revealed significant advancements, including implementing handwashing facilities; an increase in the availability of medical supplies; local manufacturing of medical devices and supplies; creating digital health platforms: enhanced support from partner organizations; and expedited medication refills. Reflecting on lessons for future pandemics, it became evident that there is a crucial need for sustained health service provision, ongoing awareness campaigns, comprehensive emergency preparedness, and building a resilient health system that can withstand natural and man-made emergency problems.

Disease prevention behaviour such as practicing hand hygiene and wearing masks, have emerged as important opportunities from the pandemic. While these practices were learned and widespread adoption were improved across various sectors due to the fear of COVID-19 transmission [17]. The rigorous adherence to hand washing and mask-wearing played a pivotal role in preventing COVID-19 and likely curtailed the spread of other hygiene-related infections and airborne diseases [18]. Respondents expressed confidence in their continued benefits for disease prevention within their communities. This trend aligns with evidence highlighting the significant role of hand hygiene and mask use in disease prevention [4].Scholars have observed a global improvement in hand hygiene practices as a direct outcome of the COVID-19 pandemic [19].

However, there is evidence suggesting that some communities have experienced a decline in the adoption of these practices post-COVID-19, possibly due to a perceived decrease in the risk of exposure [20].

Some of the innovations realized during COVID-19 were hardly adopted during normal times, as routine health services are very busy by nature. Despite this fact, the COVID-19 pandemic produced the silver lining of inspiring healthcare innovation around the world, with collaboration across multiple disciplines all working toward the same goal of saving lives [2]. The COVID-19 pandemic has accelerated and transformed the use of digital technology within healthcare [11]. During COVID-19, the quantity and speed of innovative responses to the crisis were extraordinary [9]. This is due to the fact that problems with which you stand can also lead you to seek further solutions and techniques to overcome them. COVID-19, hence, induced fear and anxiety, triggering innovations in the health system that focused on continued service delivery, for instance, the conduct of virtual meetings, which have introduced a reduction in expenditure. That is, the cost of transportation and accommodation for meetings and discussions was substituted with virtual meetings and the use of online platforms to communicate.

Virtual care, although not comprehensive in its coverage, became prominent. However, its effectiveness in revenue generation and overall patient service requires careful examination [11]. This is consistent with the Future Health Index study, which highlights pathways to broader acceptance of connected healthcare. Insights suggest barriers that hinder wider digital adoption, despite successful online patient consultations and medication provisions for chronic conditions like NCDs [10]. This suggests scaling up these strategies after conducting feasibility studies in the post-pandemic period compared to COVID-19 times when information and time for research to verify these initiatives was scarce [11].

The state of medical emergency made it possible to pool resources from financial aid and partner support directed towards the formation of a resilient health system for pandemic prevention and response. This saw an increase in access to medical supplies like masks and gloves and advancement in health infrastructure, like the establishment of oxygen production plants and tree planting ventures [12]. These are rendered opportunities, as their establishment contributes to achieving universal health coverage [13].

Lessons learned prompted respondents to recommend ensuring the continuous provision of health services during pandemics, including enhancing emergency preparedness services and increasing pandemic awareness for better response and prevention in the face of future pandemics. One important lesson learned from the pandemic is the critical need to ensure continuous access to vital healthcare services. The disruption of non-COVID medical services during COVID-19 resulted in negative health outcomes for patients with chronic illnesses and other conditions. This experience was not unique to Ethiopia [21]. To counteract this, suggestions frequently advocate for creating strong contingency plans that prioritize the continuity of essential healthcare services even amidst a pandemic. This includes strategic policy and implementation of interventions to ensure deliberate resource allocation, planning for workforce needs, and ensuring the readiness of healthcare infrastructure [22]. Raising awareness about pandemic control and management measures was deemed crucial, especially given the significant challenges posed by misinformation and gaps in knowledge regarding COVID-19 epidemiology and management, such as vaccination efforts. This aligns closely with numerous findings and recommendations put forth by various scholars, highlighting the widespread nature of this challenge across many regions during the COVID-19 pandemic [23]. Emphasis is centred on ensuring that information channels are accessible and reliable in delivering accurate information to the target population and further address information gaps for the intended audience [24–26].

Comparison with literature

COVID-19 has created an opportunity to enhance the access to critical care medical supplies, including oxygen machines, mechanical ventilators, and other intensive care unit equipment. This in line with other systematic review studies, such as the one conducted by by Menbew Sultan et al., in 2021, published and unpublished documents from the Ethiopian Ministry of Health [22].

The role of community and private sector support in controlling the COVID-19 pandemic in Ethiopia has been exceptional. This finding is consistent is with evidence from the United Nations Department of Economic and Social Affairs Sustainable Development Outlook 2021, which reveals that community and private partner engagement is crucial for effective emergency control [27]. This underscores the attention and efforts of Ethiopian government, which mobilized private stakeholders and all relevant parties in response to the public health emergency [28].

A key lesson from Ethiopia’s COVID-19 pandemic response was the integration of pandemic response initiatives with routine healthcare services to sustain ongoing care. This integration allows patients with other medical conditions to get continuous care while promoting collaboration among different healthcare units to improve care in future challenges, particularly in resource- limited settings. This is consistent with findings from studies conducted in the USA [8], as well as result from Asia, Sub- Saharan Africa, and Latin America [29].

Online or virtual training for healthcare workers has significantly contributed toeffective resource utilization, capacity building, and keeping healthcare providers updated on contemporary issues. This approach is also crucial in reducing the risk of infection during travel at time pandemic like COVID-19. This finding aligns with the study results reported by Marina Martínez-Payá. et al. in 2022 [30].

The current study’s findings underscore the importance of public awareness in the control of pandemic, which is consistent with a qualitative study conducted in the Wolaita zone of Southern Ethiopia by Eskinder Wolka et al. [25].

The pandemic has also influenced the care of patients with chronic diseases, such as the provision of multi-month supplies of medication to promote adherence. This is consistent with research conducted by Chhabi Lal Ranabhat et al. by Chhabi Lal Ranabhat [3].

According to the current study, there was a significant behavioral change regarding compliance with handwashing and other disease prevention strategies. This change has considerable advantages for controlling and preventing infectious diseases, such as diarrheal and respiratory illnesses [3]. The results are a consistent with systematic review and meta-analysis conducted by Mingming Liang et al. [19], and other research findings from India [18]. These indicate a need for a societal shift in behaviour change across all age groups within the community, as well as among healthcare providers [18].

Implications for policy and practice

The lessons learned from the COVID-19 pandemic were reflected in the successful containment of Mpox and Marburg virus diseases in the country before could escalate into crises similar to those experienced during COVID-19. Both easily containment of diseases were assured at the site of their detection before it propagates to the neighbors settings [31–33]. Establishing health confederation that considers public and private partnerships was strengthened. The partnership has been resulting by creating sustainable platforms that enable collaboration between the private and public sectors for healthcare provision and emergency preparedness. It has brought significant result by participating to the control of public health emergency situation including Mpox, Marburg, and other man-made emergency situations. National efforts by the Ethiopian government to leveraging technology and innovation must be strengthened within each healthcare setting to maximize clients need and service quality including at time of emergency.

This reveals necessity for increase investment in a health system that is resilient to public health threats, as well as the need for adequate resource allocation to the health sector to enable preparedness and response to public health emergencies.

Future research

There should be studies on the level and extent of improvement in access to essential services and critical care centers at the time of the pandemic.

There should be study on the extent and level of public private partnership engagement and impact, there should be studies focusing on facilitators, and barriers to equitable access and quality of virtual training as well as care for patients with chronic diseases at time of public health emergency.

There might be some unreported facility-level immediate response action created at each service-providing treatment center in response to the challenge of the encounter for service provision. Therefore, there should be a large-scale study considering all regions and city administrations to investigate innovation for health care during the pandemic response in Ethiopia.

Evidence is revealing that most fecal-oral and respiratory tract infections were significantly decreased following strict handwashing and the adoption of other disease prevention strategies, like the avoidance of handshakes. There should be a study on the role of this significant action using multi-methods by covering all regions within Ethiopia.

Strengths and limitations

Data were collected using phenomenology hence eliciting responses based on lived experiences. Our findings are limited by the lack of ongoing assessment regarding the sustained integration or maintenance of the discussed opportunities. Furthermore, limited access to digital technology across the country, and issues related to workforce adaptation as well as sustainability of behaviors which result into gaps for services as it cannot be taken as opportunity or lesson. Moreover, the study was conducted after years of pandemic starting. There might be possibility of recall bias from participant. However, these opportunities and lessons can still serve as focal points for strengthening health systems in preparation for future pandemics. This study is one of its first kind that dealt with the positive sides of COVID-19 because a lot has been said about COVID-19’s impacts on health care in Ethiopia.

Researcher reflexivity and positionality

Most of the researchers were from the Ethiopian Public Health Institute (EPHI), which might be assumed to affect data collection and interpretation. However, there are other authors taking part within the study to balance this issue.

Conclusions

The COVID-19 pandemic has contributed to other infection prevention activities those can be prevented by hand hygiene like faecal-oral disease, NTD like trachoma, as well upper respiratory diseases from common cold to lung disease. Furthermore, there were emergence, and utilization of health technologies like virtual care and meeting, pedal hand washing and soap application technologies, mechanical ventilators, and oxygen machines. This innovation and advances in medical technologies would have been difficult to achieve at the same pace under routine conditions. There were also lessons obtained from COVID-19 related to time management and resource sharing across facilities and between private and government. Additionally, there were success in ensuring continued provision of other health services, creating awareness in communities, allocating funds for emergencies, strengthening emergency preparedness and building a resilient health system that can withstand natural and man-made emergency problems were experienced in Ethiopia. It can be said that it was a time that most of the innovation for health were undertaken and integrated into routine health services, as well as increased attention to health issue was remarkable. Therefore, this created a conducive opportunity to sustain services through engaging the community, private sector and other partners, innovators by having regular consultative forum to ensure that the valuable innovations and lessons learnt from the pandemic benefits health service delivery and preparedness for any future pandemics.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CDC

Centers for Disease Control and Prevention

COVID-19

Coronavirus Disease 2019

HIV

Human Immunodeficiency Virus

IRB

Institutional Review Board

KII

Key Informant Interview

MoH

Ministry of Health, TB-Tuberculosis

Author contributions

GF, AT, SA, GT, MH, GB, FK, RRA: conception of the study, study design, data collection and analysis, interpretation of data, drafting and revision of the manuscript. DA, JBT, YW, AAT, RRA, LM, JB, TM, TS, ND, MPF, study design, data collection, data analysis, interpretation of results, drafting and revision of the manuscript. All Authors have revised and approved the manuscript.

Funding

This work was supported by the Africa CDC Saving Lives and Livelihoods Initiative in partnership with the MasterCard Foundation.

Data availability

Data will be available upon request to the corresponding author, ensuring that the data sharing guidelines for the EPHI, EPHA and Africa CDC are adhered to.

Declarations

Ethics approval and consent to participate

The protocol was approved by the Ethiopian Public Health Institute Review Board and Ethical clearance was issued with Ref. No. EPHI-IRB-486-2022 on date February 4, 2023 from Scientific and Ethical Review Office (SERO) which is located in Ethiopia Public Health Institute, Addis Ababa Ethiopia. The detail information if the scientific and ethical review office (SERO) can be accessed using: https://ephi.gov.et/about-us/departments-units/scientific-and-ethical-review-office-sero. The study adhered to the Declaration of Helsinki. A support letter was written to the Ministry of Health and the ministry directed a cooperation letter to each director within which the programs were governed. Written Informed consent was obtained from each respondent before interviewing. Confidentiality of individual respondents’ information was ensured using unique identifiers for study participants. Participation in the study was voluntary and they were informed of their right to withdraw from participation at any time during the interview. Data collected for this study were anonymized by de-linking personal information from the main data. The interview was carried out in a private room that ensured the privacy of the respondent.

Consent for publication

Not applicable.

Disclaimer

The views expressed in this article are those of the authors and not an official representation of the MOH, EPHI, EPHA, IDI, AFREhealth, Africa CDC or Mastercard Foundation.

Human protection

All processes of this research were in line with research ethics of human population and all authors had provided their consent prior to participation.

Competing interests

The authors declare no competing interests.