Implementation of the National Quality and Safety Strategy (NQSS-II) has contributed to measurable improvements in key health outcomes.

The NQSS-II Mid-Term Review report indicated that significant progress had been made in 12 of the 17 targeted NQSS indicators. Moreover, selected institutional health outcome indicators from the routine health information system showed consistent improvements from 2019/20 to 2024/25.

• Institutional maternal mortality decreased from 41 to 30 per 100 000 live births
• Early institutional neonatal death rate reduced from 5.3 to 4.3 per 1000 births
• Stillbirth rate declined from 14.3 to 9.3 per 1000 births
• Inpatient mortality rate reduced from 2.3% to 1.6%.

Alongside this, the recent UN MMR report revealed that the Ethiopian maternal mortality ratio (MMR) declined to 195 per 100 000 live births in 2023, meeting the country's target of 199 by 2025/26. Overall change in MMR between 2020 and 2023 indicated a 20% decline, from 244 to 195 per 100 000 live births. On the other hand, the people voice survey also revealed client experience of care was 45% in 2022, highlighting progress in people centered service delivery compared to the NQSS-II baseline figure of 33%.

The Second National Quality and Safety Strategy (2021–2025) continued the first national health care quality strategy (2016–2020), and its development was informed by the final evaluation of the previous strategy. The development process involved three teams. The writing team was responsible for drafting the strategic document; the technical team provided technical input through consultative workshops; and the national quality steering committee provided guidance and approval on the overall strategy.

The preparation passed through different phases, with the total duration of the plan preparation taking four months.

The development of the 2021–2025 strategy was informed by the WHO’s Handbook for National Quality Policy and Strategy and followed the Plan Commission’s Guide to strategic plan preparation (Strategic planning and management), with slight modifications. Furthermore, the Lancet Global Commission's High quality health systems in the Sustainable Development Goals era: time for a revolution; the Organisation for Economic Cooperation and Development/WHO/World Bank's Delivering quality health services: a global imperative for universal health coverage and the National Academy of Medicine, Science, and Engineering's Crossing the global quality chasm worldwide: improving health care reports, were also closely consulted.

Another important reference was the Global Action Plan on Antimicrobial Resistance (2015), which influenced many key interventions in our strategy, particularly those related to medication and infection safety. Its five strategic objectives guided our focus on infection prevention and control systems, antimicrobial stewardship programmes, and integrating surveillance and reporting across care settings.

To understand the evidence base and gaps in patient safety, we consulted the 2008 WHO World Alliance for Patient Safety report, Summary of the evidence on patient safety: implications for research. This document guided our situational analysis and highlighted priority areas, including unsafe medication practices, health care-associated infections, and surgical safety. These areas became essential to Ethiopia’s national patient safety interventions and research agenda.

We also aligned our strategy with the WHO Framework on integrated people-centred health services (2016), which established a solid basis for integrating people-centred principles throughout the strategy. Its five strategic approaches informed the creation of interventions that put individuals, families, and communities at the heart of care delivery. This included developing mechanisms for patient feedback, involving civil society in policy-making, and encouraging shared decision-making in care settings.

In addition, some objective and thematic matching of the Health Sector Transformation Plan II with health care quality was done. This phase was entirely carried out by the writing team. After the review, the analysis part of the quality strategy was initiated.

Initially, the technical working group (comprising departments in the Ministry of Health, professional associations, nongovernmental organizations, and bilateral organizations) took the lead. The national quality and safety technical working group extensively engaged in drafting the SWOT analysis, stakeholder analysis, national quality and safety framework, and goals and objectives. Consultative workshops were organized along with the regular technical working group meetings. After receiving the draft outputs, the national quality steering committee provided constructive feedback. Then developments continued, with the writing team playing an active role. Intervention and priority areas were suggested by the writing team and presented to the national technical working group. After having the priority areas and interventions suggested, national implementation arrangements and monitoring and evaluation frameworks were drafted.

Agencies and regional health bureaus were engaged through consultative workshops, and constructive feedback was given on the drafted national quality and safety strategy. A costing exercise was conducted after the draft strategy had undergone successive rounds of feedback. Finally, the strategy was approved by the National Quality Steering Committee.

The NQSS-II development posed some challenges, which were mitigated:

One of the challenges was the limited availability of comprehensive data on the current state of health care quality in Ethiopia, primarily due to insufficient quality-adjusted measures by service area and data quality issues in existing indicators.
→ To address evidence gaps and data quality challenges, the process incorporated qualitative findings from the end-term evaluation of the previous strategy, along with emerging global evidence.

Additionally, a lack of community engagement was a key challenge in gaining their voice and perspectives. There was also limited engagement from a broad range of stakeholders, mainly key executive offices within the Ministry of Health and relevant government agencies, in the development process.
→ Stakeholder and community engagement was strengthened by leveraging existing platforms such as patient groups and professional associations, as well as participatory mechanisms including client satisfaction assessments, town hall meetings, and community scorecards, to ensure community voices informed priorities and performance monitoring.

On the other hand, though engagement among implementing partners was very good, some of them have posed challenges in pushing their influence on the content of the strategy. Competing priorities within the health sector, caused by the COVID-19 pandemic, also understandably delayed the strategy's timely endorsement.
→ Broader partner engagement was ensured to capture diverse perspectives, while individual consultants were hired to accelerate delayed activities.

The other challenge was a technical one: ensuring the strategy reflected both national priorities and the latest global evidence on quality of care, as reflected in the strategy's formulation. The formation of the National Quality and Safety Strategy II (NQSS-II) framework, developed through aligning with the Health Sector Transformation Plan II (HSTP-II) and integration of the key recommendations from three major global reports on quality of care published in 2018, posed a challenge that led to extensive consultation and debate among a wide range of stakeholders.
→ To balance national priorities with global recommendations, extensive consultations and technical debates were conducted among Technical Working Groups (TWGs) and experts, ensuring alignment and consensus in the strategy development process.

Since the launch of Ethiopia's National Quality and Safety Strategy (NQSS 2021–2025), the country has shifted from scattered, project-based efforts to a united programme.

A cohesive quality-management system now connects the Ministry of Health, regional bureaus, health care facilities, and communities through a Health System Innovation and Quality Lead Executive Office and a network of local quality units. This structure has integrated health innovation, health care quality and safety, health care accreditation, infection prevention and control, health equity, and leadership development as key, mutually supporting functions.

To speed up implementation, a tiered set of coordination and learning platforms was established. These include the National Health Innovation and Quality Steering Committee, MOH-RHB, a Joint Quality and Equity Forum, an Innovation & Quality Research Advisory Council, several technical working groups, and a community of practice that holds monthly webinars. These groups have guided the rollout of evidence-based clinical guidelines, particularly the new hospital and health-centre clinical audit guides and tools, which are now part of routine service delivery audits. Large-scale System Bottleneck Focused Reform (SBFR), which focused on removing obstacles, has been tested in 45 high-load public hospitals, leading to measurable improvements in maternal death reviews, antibiotic use, and client experience scores. The lessons learnt are being shared with 31 primary health care unit districts.

Institutional sustainability is being strengthened through Ethiopia's first national health-facility accreditation programme. Hospital accreditation standards were officially endorsed by the Ethiopian Standards Agency in 2025, and draft standards for health centres have been released for public feedback. Along with accreditation, Ethiopia has shifted from using crude coverage metrics to effective coverage metrics supported by a national guide, an indicator compendium, a database, and a training package. A user experience guide and tools, alongside community scorecards and patient feedback kiosks, provide actionable insights that facilities can respond to immediately.

Patient safety has become a priority in Ethiopia. National guidelines, training programmes, and the Patient Safety-Friendly Hospital Initiative are now in place across the country, encouraging a culture that supports nonpunitive incident reporting.

Leadership programmes provide facility managers with skills in quality improvement, resource mobilization, and budgeting, while thorough quality improvement training, mentoring, and coaching packages have been delivered across regional health bureaus, hospitals, health centres, and community settings.

Knowledge sharing has increased through global, national, regional, and health facility quality summits, as well as EHAQ/EPAQ networks, learning visits, and newly created accessible innovation and quality hubs that serve as repositories of tools and examples.

Challenges encountered during the implementation include:

• No earmarked budget line for quality and safety activities at the subnational levels, affecting the scale and sustainability.
• The COVID-19 pandemic, inflation, and a decline in donor support have significantly disrupted momentum in implementation.
• Many health facilities face challenges in providing quality care due to inadequate basic amenities such as electricity, clean water, and a consistent supply of essential commodities and diagnostics.
• Implementation of performance-based financing schemes to incentivize quality care has been limited, with only a few pilot initiatives underway.

To address the key challenges, the Ministry of Health and its partners have undertaken the following strategic actions:

• New platforms have been introduced, including a national steering committee that actively engages MOH senior leadership, donors, programme implementers, and key Partners to ensure aligned efforts, resource mobilization, and enhanced coordination support.
• The MOH has convened joint forums with regional health bureaus and implementing partners to accelerate the implementation and monitoring of NQSS-II. Large-scale, innovative projects such as the System Bottleneck Focused Reform (SBFR) have been implemented.
• High-impact leadership programmes have been introduced, and capacity-building training has been provided for strategic, mid-level, and frontline leaders.
• Nationally costed infrastructure roadmaps have been developed for the health facility infrastructure integrated plan and development.
• Strengthening infection prevention and control practices through developing and implementing the National IPC Policy, Strategy, and Guidelines.

Community engagement was limited during the development process, resulting in gaps in both community awareness and ownership of certain initiatives.

Moving forward, the next quality strategy must be deeply informed by findings from comprehensive assessments, including the state of care quality, patient safety, and health equity. This will ensure that future strategies are holistic, inclusive, and responsive to both emerging innovations and the needs of all stakeholders, including the wider community.