Experience of COVID-19 Response in Addis Ababa City Administration, Ethiopia: a mixed-methods implementation study

Experience of COVID-19 Response in Addis Ababa City Administration, Ethiopia: a mixed-methods implementation study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Experience of COVID-19 Response in Addis Ababa City Administration, Ethiopia: a mixed-methods implementation study Mulugeta Abate Hailemariyam, Daniel Damtew Woldetekle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8498540/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Urban centers in low- and middle-income countries faced substantial operational challenges during the COVID-19 pandemic. Addis Ababa, Ethiopia’s political and economic hub, implemented a comprehensive, multisectoral response coordinated through an Incident Management System (IMS) and Emergency Operations Center (EOC). Methods We conducted a mixed-methods implementation study synthesizing routine surveillance and programmatic data (March 2020–June 2023), policy and operational documents, and key informant interviews across surveillance, laboratory, logistics, case management, risk communication and community engagement (RCCE), and vaccination pillars. Quantitative indicators were descriptively analyzed; qualitative data were thematically analyzed and triangulated. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Results Addis Ababa expanded surveillance and laboratory capacity through decentralization, scaled contact tracing, implemented home-based isolation and care, strengthened infection prevention and control, mobilized logistics and supply chains amid global shortages, and achieved high vaccination coverage through phased roll-out. Governance via IMS/EOC enabled coordination across eleven sub-cities and partners. Major challenges included supply chain disruptions, workforce fatigue, misinformation, and data integration constraints. Adaptive strategies—task force governance, community engagement via Family Health Teams, and evidence-informed decision-making—mitigated system strain. Conclusions A centralized IMS/EOC with decentralized implementation, strong RCCE, and flexible logistics were pivotal to sustaining urban pandemic response. Institutionalizing emergency management capacity and investing in data systems are critical for future preparedness. COVID-19 Public health emergency Incident Management System Emergency Operations Center Urban health Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Background COVID-19 exposed structural and operational vulnerabilities of urban health systems worldwide. In sub-Saharan Africa, early concerns focused on constrained laboratory capacity, supply chain fragility, and dense urban transmission dynamics. Addis Ababa—home to major transport hubs, diplomatic missions, and a heterogeneous population—required rapid coordination across health and non-health sectors. Ethiopia reported its first COVID-19 case in March 2020, prompting activation of emergency governance and public health measures aligned with International Health Regulations (2005). The number of tests, admission and related outcomes from March 2020–2023 showed in Fig. 1 . Methods Study design and setting This study employed a mixed-methods implementation design to document and analyze the COVID-19 response of the Addis Ababa City Administration Health Bureau (AACAHB) from March 2020 to June 2023. The study was conducted across the eleven sub-cities of Addis Ababa and covered all major response pillars coordinated through the Incident Management System (IMS) and Emergency Operations Center (EOC). The mixed-methods approach was selected to capture both measurable system performance and implementation experiences, enabling a comprehensive assessment of how governance structures, operational strategies, and contextual factors shaped the urban pandemic response. Quantitative data sources and analysis Quantitative data were obtained from routine surveillance and programmatic databases, including COVID-19 testing records, case notifications, hospital admissions, recoveries, deaths, logistics and supply distribution records, and vaccination registries. Data were sourced from surveillance, laboratory, logistics, case management, RCCE, and vaccination pillars and compiled at city, sub-city, and facility levels. Descriptive analyses were conducted to summarize trends over time, including testing volume, case positivity, admissions, mortality, and vaccination coverage. Indicators were analyzed by transmission phase relevant to reflect shifts in response strategy. Quantitative findings were used to characterize system scale-up, service continuity, and response outputs. Qualitative data sources The qualitative component consisted of key informant interviews (KIIs), desk review of operational documents, and validation workshops. KIIs were conducted with purposively selected informants who had direct involvement in planning, coordination, or implementation of the COVID-19 response. The semi-structured interview guide was developed specifically for this study based on WHO emergency response pillars and adapted to the local COVID-19 response context. The English version of the interview guide is provided as Supplementary File 1. Participants included IMS and EOC leadership, pillar leads, sub-city coordinators, frontline managers, and technical experts from surveillance, laboratory services, logistics and supply chain management, case management and IPC, RCCE, vaccination, and planning and evidence synthesis units. Informants represented both strategic and operational levels to capture system-wide and frontline perspectives. Each interviewee was assigned a unique anonymized identifier (KII-01, KII-02, etc.) to preserve confidentiality while allowing traceability of themes across response pillars. Data collection procedures Semi-structured interview guides were developed based on WHO emergency response pillars and adapted iteratively as the response evolved. Interviews explored preparedness, coordination mechanisms, operational adaptations, workforce experiences, community engagement, ethical dilemmas, psychosocial impacts, and lessons learned. Interviews were conducted in Amharic or English, audio-recorded with informed consent, and supplemented with detailed field notes. Interviews continued until thematic saturation was achieved across pillars. Qualitative analysis Interview recordings were transcribed verbatim and translated into English where necessary. A thematic approach was applied, combining deductive coding aligned with predefined response pillars and inductive coding to capture emergent issues not initially anticipated. An initial codebook was developed and refined iteratively. Two analysts independently coded transcripts, reconciled discrepancies through discussion, and grouped codes into higher-order themes reflecting governance, implementation processes, adaptations, constraints, and lived experiences of responders and communities. Integration of quantitative and qualitative findings Quantitative and qualitative findings were integrated at the interpretation stage. Quantitative trends were used to contextualize qualitative narratives, while qualitative findings explained the mechanisms, challenges, and human dimensions underlying observed system performance. Ethical considerations Ethical approval was obtained from the Addis Ababa City Administration Health Bureau Research Ethics Committee. All participants provided informed consent prior to participation. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Results Leadership, coordination, and governance Early establishment of the Incident Management System (IMS) and Emergency Operations Center (EOC), Shows in Fig. 2, created a shared operational architecture that guided the COVID-19 response across all administrative levels. Informants described the IMS as central to role clarity, rapid decision-making, and reduction of fragmentation among response pillars. “Once the EOC was activated, everyone understood where decisions were coming from and where to report. That clarity was critical during the early chaos.” (KII-03, EOC Coordination) As transmission intensified, governance arrangements adapted to balance centralized strategic oversight with decentralized operational authority. Sub-city and woreda teams were increasingly empowered to tailor implementation to local contexts. “We learned quickly that central control alone would not work. When cases surged, decentralization was not optional—it was survival.” (KII-07, Sub-city Lead) These adaptive governance processes facilitated continuity of response across multiple waves. Surveillance and contact tracing. Surveillance strategies evolved in response to escalating transmission and operational constraints. Initial phases emphasized exhaustive contact tracing, while later stages prioritized targeted tracing in high-risk settings such as markets, prisons, schools, and densely populated neighborhoods. The algorithm applied in the first phase showed in Fig. 3. “At first, every contact was followed. Later, when numbers exploded, we had to trace strategically. Otherwise, the system would collapse.” (KII-11, Surveillance Officer) The algorithm applied for contact tracing during phase 2 is shown in Fig. 4. Community fear, stigma, and mistrust occasionally disrupted surveillance and containment efforts, particularly following deaths or delays in test results. “After a suspected COVID-19 death in Addis Ketema, the family buried the body before results were released. When contact tracing began, the team faced hostility and had to flee.” (KII-14, Contact Tracing Supervisor) These incidents illustrate how external contextual factors shaped implementation fidelity. From February 2021 onward, contact tracing and follow-up activities were reshaped from exhaustive contact tracing approach to targeted contact tracing approach. at the woreda, and facility levels and activities were decentralized at each level. The activities of contact tracing throughout the outbreak showed in Fig. 5. Laboratory system expansion and constraints Laboratory capacity expanded through decentralization and engagement of additional public and private facilities. Informants emphasized that this expansion improved access to testing and supported timely decision-making. “When private laboratories were integrated and machines were decentralized, turnaround times improved and response decisions became faster.” (KII-05, Laboratory Lead) Between 20 March 2020 and 05 May 2023, a total of 2,731,850 laboratory tests were performed, both in Ag-RDT and in PCR, in Addis Ababa. For PCR purposes, eight public and twenty-four private RT PCR testing sites were established. A total of 2,819 tests were performed on specimens collected from a dead body between 29 March 2021 and 1 May 2023. Among these tests, 446 (16%) were positive. The majority (99%) of the results were released in three days, while 83% were notified within one day. The positivity rate was higher in the NSL (13.2%) and Yeka (12.7%) sub cities (Fig. 6). Private health facilities contributed for 60% of tests.(Fig. 7) Despite these gains, global shortages of reagents and consumables required continuous prioritization and operational flexibility. Logistics and supply chain resilience Despite global shortages, AACAHB mobilized procurement, donations, and local production (e.g., alcohol-based hand rub), maintained biomedical equipment, and distributed essential supplies to facilities using adaptive allocation frameworks, and distributed supplies that cost 788,384,654.79 ETB (Table 1). Table 1 Cost of pharmaceuticals and medical supplies received from different organisations in support of COVID-19 response sn Categories Total price received 1 Pharmaceuticals Supplies 573,286,158.84 ETB 2 Medical equipment 205,698,642.00 ETB 3 other medication( Different medicines) 9,399,853.95 ETB Total price 788,384,654.79 ETB Biomedical maintenance teams restored non-functional ventilators and critical devices, mitigating equipment shortages and sustaining facility functionality during peak periods. Case management, IPC, and health workforce experience Facility readiness, referral systems, and the introduction of home-based isolation and care (HBIC) reduced hospital burden and preserved capacity for severe cases. Isolation and treatment capacity expanded alongside the introduction of home-based isolation and care, preserving hospital capacity for severe cases. Beneath these operational achievements, informants described profound personal and psychosocial strain among health workers. “For more than a year, I lived away from my family—just a few hundred meters from home. I missed funerals and all social life. When I tested positive myself, the psychological impact was worse than the physical symptoms.” (KII-01, IMS Leadership) During peak transmission periods, illness and death among patients and colleagues further intensified emotional distress. “By late 2020, exhaustion was everywhere. I was admitted to ICU for ten days and witnessed eight deaths around me. It was deeply distressing.” (KII-18, Case Management Lead) These experiences underscore the limited integration of mental health and psychosocial support within emergency response structures. Through the HBIC program, over 302,000 patients were managed at home, with more than 98% recovering, reducing pressure on institutional care (Table 2, Fig. 8). Table 2 home isolation and care situation as of June 14/2023 in Addis Ababa. Total admission to HBIC 302, 479 Recovered 297,764 Death 30 transfer to the treatment center 2334 Number of HCWs admitted 731 Number of HCWs recovered 731 Risk communication and community engagement (RCCE) A citywide RCCE strategy leveraged Family Health Teams, mass media, and community networks to address misinformation, promote preventive behaviors, and support vaccination uptake. Risk communication strategies relied heavily on trusted local actors, including Family Health Teams, religious leaders, and community volunteers. Informants emphasized that trust, rather than message volume, determined uptake. “People listened more to health workers and community leaders they knew than to national announcements.” (KII-12, RCCE Coordinator) Misinformation and stigma, particularly in early phases, undermined adherence to prevention measures and delayed care-seeking. To improve COVID-19 preventive and control strategies, the team uses engagement principles to involve the community, stakeholders (schools, workplaces), and partners. Community mobilization networks, including youth associations, volunteers, Edir ( Traditional social organization to support each other, especially during mourning), WDA (Women Development Army), condominium associations, community-based organizations, and religious leaders, are key players in the implementation of community engagement. Community engagement was driven by volunteers, youth groups, and religious leaders who promoted prevention measures, vaccination, and adherence to public health directives, while providing psychosocial support. RCCE activities also reached schools and workplaces through targeted information sharing and vaccination promotion. Trends of key message dissemination plan and performance seen in Fig. 9. Ethiopia has officially launched the “No Mask No Service National Campaign” January 30/2021 as part of an effort to fight coronavirus pandemic across the country. The measure which is effective at all schools in the country is said to have a paramount importance in curbing the spread of the virus in schools thereby protecting the teaching learning process from disruption due to the pandemic. Students have been urged on the occasion to adhere to mask wearing measure out of schools to protect the community from COVID 19. Vaccination rollout and equity considerations Vaccination delivery combined fixed-site services with outreach and mobile strategies to reach informal settlements and marginalized populations. Informants consistently linked improved uptake to integrated community engagement. “Fixed sites alone could not reach informal settlements. Outreach teams and community mobilization made the difference.” (KII-16, Vaccination Coordinator) Vaccine hesitancy remained closely associated with misinformation, perceived risk, and trust in institutions. Phased vaccine introduction prioritized high-risk groups, scaled fixed and outreach services, and coordinated multisectoral mobilization to improve coverage. The overall performance of the vaccination activity shown in Table 3. Target prioritization and registration had been supported and conducted based on the national prioritization guidelines. Table 3 Addis Ababa COVID-19 vaccination ststus ( March 13,2021-July 16,2023) Key challenges included supply chain volatility, workforce burnout, misinformation, and data fragmentation. Financial constraints necessitate prioritization and partner support. Discussion As demonstrated in the Results, across all pillars, the COVID-19 response in Addis Ababa was shaped by adaptive leadership, decentralized implementation, and sustained commitment of health workers and community actors. While operational continuity was maintained across successive waves, qualitative findings reveal the significant human, psychosocial, and ethical costs associated with prolonged emergency response in a dense urban setting. This approach is consistent with the WHO COVID-19 Strategic Preparedness and Response Plan, which emphasizes strong coordination mechanisms and adaptive governance in public health emergencies [ 1 ]. Such institutional arrangements are particularly important in large urban settings with complex administrative structures. The governance arrangements observed in Addis Ababa also align with the requirements of the International Health Regulations (2005) and the WHO Emergency Response Framework, both of which stress timely detection, reporting, and coordinated response as core capacities for health security [ 2 , 3 ]. The Results show that centralized strategic oversight combined with decentralized operational implementation supported continuity of essential response functions across successive waves of the pandemic. Expansion of surveillance and laboratory capacity, as reported in the Results, was guided by national policies and technical standards. The Ethiopian Public Health Institute’s national COVID-19 management handbook provided an operational framework for integrating surveillance, laboratory testing, and case management [ 4 ], while routine situation reports documented adaptive implementation at city level [ 5 ]. These actions addressed early concerns about Africa’s vulnerability to COVID-19 due to health system constraints and high transmission risk in urban areas [ 8 , 9 ]. Risk communication and community engagement (RCCE) strengthened adherence to public health measures and supported vaccine uptake, consistent with WHO guidance [ 1 ]. Overall, the Results support evidence that early, coordinated responses in African settings yield substantial health and economic benefits [ 7 ]. The mixed-methods design enhanced interpretation by linking implementation processes with outcomes, in line with established methodological guidance [ 6 ]. This mixed-methods implementation study documents the COVID-19 response in Addis Ababa and situates it within the broader experience of African urban health systems during the pandemic. The findings demonstrate that centralized emergency governance through an Incident Management System (IMS) combined with decentralized operational execution was a critical enabler of timely decision-making, partner coordination, and adaptive response. Similar governance arrangements were reported in Lagos State, Nigeria, where Emergency Operations Centers coordinated multisectoral actors and improved situational awareness, though subnational fiscal and workforce constraints remained [ 10 , 11 ]. In South Africa, metropolitan municipalities integrated COVID-19 command councils with disaster management structures, facilitating continuity of essential services while scaling epidemic control measures [ 12 ]. Surveillance and laboratory decentralization were pivotal to Addis Ababa’s response. Expansion of testing capacity through public–private partnerships and phased introduction of rapid antigen diagnostics reduced turnaround times and supported targeted interventions. Comparable strategies were reported in Nairobi and Johannesburg, where decentralized testing and community screening enhanced early detection and outbreak control [ 13 – 15 ]. Persistent fragmentation between surveillance, laboratory, and vaccination data systems mirrors challenges reported in Accra and Dar es Salaam, underscoring the need for interoperable digital platforms [ 16 , 17 ]. Risk communication and community engagement (RCCE) emerged as a cornerstone of response effectiveness. Addis Ababa’s Family Health Team–led engagement aligns with evidence from Kampala and Accra showing that trusted community intermediaries significantly improved adherence to non-pharmaceutical interventions and reduced misinformation [ 18 – 20 ]. Studies from Senegal and Rwanda further indicate that transparent communication strengthened public trust in government-led responses [ 21 , 22 ]. Case management and health system resilience were strengthened through home-based isolation and care models, reducing hospital congestion and preserving capacity for severe cases. Similar approaches were implemented in Cape Town and Casablanca with positive effects on bed availability and healthcare worker safety [ 23 , 24 ]. Nonetheless, workforce fatigue and psychosocial stress—widely reported across African settings—highlight the need for sustained investments in health worker well-being and surge staffing mechanisms [ 25 , 26 ]. Vaccination rollout strategies benefited from phased prioritization, outreach services, and multisectoral mobilization. Evidence from Nairobi, Kigali, and Lagos indicates that mobile vaccination units and community-based delivery models improved access in urban informal settlements [ 27 – 29 ]. Persistent vaccine hesitancy, also observed elsewhere in Africa, emphasizes the importance of integrating RCCE with immunization planning [ 30 ]. Overall, Addis Ababa’s experience reinforces regional evidence that urban pandemic preparedness requires institutionalized emergency management capacity, interoperable data systems, resilient supply chains, and sustained community engagement. Conclusions The COVID-19 response in Addis Ababa demonstrates that large, complex urban health systems in low- and middle-income countries can sustain effective pandemic control when centralized emergency governance is combined with decentralized, context-sensitive implementation. Early activation of the Incident Management System (IMS) and Emergency Operations Center (EOC) provided a coherent command structure that enabled coordination across eleven sub-cities, rapid decision-making, and adaptive management across successive epidemic waves. The response was strengthened by timely expansion of surveillance and laboratory capacity, flexible logistics and supply chain mechanisms, community-centered risk communication, and the introduction of home-based isolation and care models that preserved hospital capacity. At the same time, qualitative findings reveal the substantial human, psychosocial, and ethical costs borne by frontline responders and communities—costs that are often under-recognized in emergency planning but are central to system resilience. This mixed-methods implementation study highlights that governance structures alone are insufficient without sustained investment in health workforce protection, mental health and psychosocial support, interoperable data systems, and trusted community engagement platforms. The Addis Ababa experience underscores the importance of institutionalizing emergency preparedness capacities beyond crisis periods, embedding IMS/EOC functions within routine health system governance, and strengthening urban health resilience in anticipation of future public health emergencies. Lessons from Addis Ababa are transferable to other rapidly growing cities facing similar demographic density, informality, and health system constraints. Building resilient urban health systems will require not only technical preparedness, but also long-term commitment to people-centered implementation, equity, and adaptive governance. Declarations Ethics approval and consent to participate: Approved by Addis Ababa Health Bureau Research Ethics Committee. Consent for publication: Not applicable. Funding: No external funding. Authors’ contributions: DD conceived the study and led implementation; MA led analysis and drafting. All authors reviewed and approved the final manuscript. Acknowledgement We acknowledge AACAHB staff, sub-city teams, health facilities, community actors, and partners for their contributions. We would like to take a moment to acknowledge the hard work and dedication of the Addis Ababa Health Bureau, and specifically the Addis Ababa Public Health Research and Emergency Management (AAPHREM) Directorate. Their commitment to excellence in public health emergency practice, stakeholders including non-government organizations support, and the community active participation, and the technical team attention to detail has resulted in successful COVID-19 pandemic management that lead to successful control of the pandemic with limited health, social, and economic impacts. Data Availability Available from the corresponding author on reasonable request. References World Health Organization. WHO COVID-19 Strategic Preparedness and Response Plan. Geneva: WHO; 2020. World Health Organization. International Health Regulations. (2005). 3rd ed. Geneva: WHO; 2016. World Health Organization. Emergency Response Framework. 2nd ed. Geneva: WHO; 2017. Ethiopian Public Health Institute. National Comprehensive COVID-19 Management Handbook. Addis Ababa: EPHI; 2021. Addis Ababa Health Bureau. COVID-19 Situation Reports (2020–2023). Addis Ababa: AACAHB; 2023. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 3rd ed. Thousand Oaks: Sage; 2018. Evans DK, Goldstein M, Popova A. Health, and economic benefits of early COVID-19 response in Africa. BMJ Glob Health. 2020;5:e003069. El-Sadr WM, Justman J. Africa in the path of COVID-19. N Engl J Med. 2020;383:e11. Nkengasong JN, Mankoula W. Looming threat of COVID-19 infection in Africa. Lancet Infect Dis. 2020;20:254–6. Adebisi YA, et al. COVID-19 response in Lagos State, Nigeria: governance and lessons learned. J Public Health Afr. 2021;12:212. Oleribe OO, et al. Identifying key challenges facing healthcare systems in Africa during COVID-19. Pan Afr Med J. 2021;39:23. Burger R, et al. COVID-19 policy responses and urban governance in South Africa. S Afr Med J. 2021;111:111–5. Were L, et al. Community-based COVID-19 testing strategies in Nairobi. Int J Infect Dis. 2021;104:594–600. Mohlabane N, et al. Decentralized COVID-19 surveillance in South African metros. Int J Infect Dis. 2021;104:628–34. Makoni M. COVID-19 testing in Africa: lessons from urban centers. Lancet Microbe. 2021;2:e238. Osei-Korankye E, et al. Data integration challenges in Ghana’s COVID-19 response. Health Policy Technol. 2022;11:100631. Kamuzora P, et al. Digital health systems and COVID-19 surveillance in Tanzania. BMC Public Health. 2022;22:1489. Mugume D, et al. Community engagement in Kampala’s COVID-19 response. Afr J Prim Health Care Fam Med. 2022;14:e1–7. Afolabi AA, Ilesanmi OS. Risk communication during COVID-19 in Africa. Pan Afr Med J. 2021;38:152. Ataguba JE. COVID-19, community trust and public health messaging in Africa. Health Econ Rev. 2020;10:28. Seck SM, et al. Community perceptions of COVID-19 in Senegal. BMC Public Health. 2021;21:1234. Binagwaho A, et al. Rwanda’s COVID-19 response: governance and trust. Lancet. 2020;395:350. Kaplan J, et al. Hospital surge capacity and home-based care models in Cape Town. S Afr Med J. 2021;111:1130–5. El Aouad R, et al. COVID-19 case management strategies in Morocco. East Mediterr Health J. 2021;27:549–56. Shaukat N, et al. Physical and mental health impacts of COVID-19 on healthcare workers. Int J Environ Res Public Health. 2020;17:3883. Temsah MH, et al. Burnout among healthcare workers during COVID-19. PLoS ONE. 2020;15:e0239454. Barasa E, et al. COVID-19 vaccine delivery strategies in Kenya. BMJ Glob Health. 2022;7:e009019. Uwizeye G, et al. Equity-focused vaccination rollout in Rwanda. Vaccines. 2022;10:1354. Hassan AO, et al. Mobile vaccination units in Lagos informal settlements. Vaccine. 2023;41:1280–7. Sallam M. COVID-19 vaccine hesitancy worldwide: systematic review. Vaccines. 2021;9:160. Supplementary. file 1. Study Title. Experience of COVID-19 Response in Addis Ababa City Administration, Ethiopia. Purpose. To explore implementation experiences, challenges, adaptations, and lessons learned from the COVID-19 response, aligned with WHO emergency response pillars. Semi-Structured Interview Guide. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1ExperienceofCOVID19ResponseinAddisAbabaCityAdministrationEthiopiaQuaitativetool.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 20 Feb, 2026 Reviewers agreed at journal 14 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor assigned by journal 03 Feb, 2026 Editor invited by journal 12 Jan, 2026 Submission checks completed at journal 09 Jan, 2026 First submitted to journal 09 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8498540","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":609773367,"identity":"901f7dcd-313d-41bd-ad56-a19a025d9ea9","order_by":0,"name":"Mulugeta Abate Hailemariyam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYFAC5gYgcQDEOPgASPLwEdbCCNHCw8CWbADSwkaCFh4zCRCfoBbdGYmNjytq7sjbszeYVX7NsZNhY2B++OgGHi1mNxKbDc8ce2bYw3Mg7bbstmSgw9iMjXPwa2mTbGA7zNgjkXDstuQ2ZqAWHjZpAlrafzb8O2zfI/+wrVhyWz1RWtoYG9sOJ/ZIMLMxftx2mAgtZx42Szb2PUvuOZPGLM247TgPGzMhvxxPPvix4dsd2/b28x8//txWbc/P3vzwMT4tKICZB0wSqxwEGH+QonoUjIJRMApGDAAAZ7BMf6bOaAYAAAAASUVORK5CYII=","orcid":"","institution":"Addis Ababa City Administration Health Bureau","correspondingAuthor":true,"prefix":"","firstName":"Mulugeta","middleName":"Abate","lastName":"Hailemariyam","suffix":""},{"id":609773368,"identity":"2a361c38-52e2-4ad6-90a9-106351289550","order_by":1,"name":"Daniel Damtew Woldetekle","email":"","orcid":"","institution":"Addis Ababa City Administration Health Bureau","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"Damtew","lastName":"Woldetekle","suffix":""}],"badges":[],"createdAt":"2026-01-02 06:23:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8498540/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8498540/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105565396,"identity":"5cfb64aa-e4ec-4c73-8808-ac7978ed4376","added_by":"auto","created_at":"2026-03-27 12:53:07","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":149409,"visible":true,"origin":"","legend":"\u003cp\u003eAddis Ababa COVID-19 test and its outcome as of June 14, 2023\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/b24af248b2899e7fedc4180e.jpg"},{"id":105565685,"identity":"c2714324-a8e0-40d7-9eaf-5de2455e4121","added_by":"auto","created_at":"2026-03-27 12:54:03","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":135795,"visible":true,"origin":"","legend":"\u003cp\u003eshows the organogram of AAEOC as of July 2022\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/1af0b00879fa548016fd39dd.jpg"},{"id":105408402,"identity":"aea5e9e5-98a8-433e-998c-53ea3b91937a","added_by":"auto","created_at":"2026-03-25 17:01:50","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":712947,"visible":true,"origin":"","legend":"\u003cp\u003ePhase I transmission scenario (March 13-April 2020) Contact tracing and follow-up approach, Addis Ababa.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/36d0f50d701ebf60af748696.jpg"},{"id":105565687,"identity":"26b12a82-f856-4846-88e7-8d53c26eb5f3","added_by":"auto","created_at":"2026-03-27 12:54:03","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":88838,"visible":true,"origin":"","legend":"\u003cp\u003ePhase II \u0026amp; III transmission scenario ( April 2020-January 2021) Contact tracing and follow-up approach\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/1a89d65d596d91a9e578f389.jpg"},{"id":105408400,"identity":"4194d02f-c5cb-4781-aa57-9a18feaa774b","added_by":"auto","created_at":"2026-03-25 17:01:50","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":102484,"visible":true,"origin":"","legend":"\u003cp\u003eContact tracing performance as of June, 2023\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/feb3df6b8257e0030e4c7f49.jpg"},{"id":105728179,"identity":"58e39790-aa44-40c7-8fdb-9074d13e34c6","added_by":"auto","created_at":"2026-03-30 11:10:41","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":311573,"visible":true,"origin":"","legend":"\u003cp\u003eRT PCR number of tests and positivity rate in sub-city administration of Addis Ababa city 20 March 2020 – 05 May 2023\u003c/p\u003e","description":"","filename":"Picture6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/32e6a9fec0ae0001bc7e528e.jpg"},{"id":105565675,"identity":"67abb89c-3755-4d8f-9bc9-2a1533c59541","added_by":"auto","created_at":"2026-03-27 12:54:00","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":114657,"visible":true,"origin":"","legend":"\u003cp\u003enumber of RT PCR tests performed in private and public testing laboratories 20 March 2020 – 05 May 2023\u003c/p\u003e","description":"","filename":"Picture7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/216aabb3534dd574c2d1202d.jpg"},{"id":105566029,"identity":"b119d3ae-7281-49a6-8aae-72ae4e37b9bd","added_by":"auto","created_at":"2026-03-27 12:55:06","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":254457,"visible":true,"origin":"","legend":"\u003cp\u003eTrend of isolation and admission to home care in Addis Ababa from October 2020 to July 2022\u003c/p\u003e","description":"","filename":"Picture8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/c75e504bec0df6a4cd35ba9a.jpg"},{"id":105566131,"identity":"1b6f0a01-4ee5-447f-9001-413c2c40382f","added_by":"auto","created_at":"2026-03-27 12:55:25","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":242518,"visible":true,"origin":"","legend":"\u003cp\u003eHousehold visit and health education by FHT from 2020-2023, Addis Ababa\u003c/p\u003e","description":"","filename":"Picture9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/26c733b8a9b807e62c046e24.jpg"},{"id":105729848,"identity":"ff8818e8-426f-4278-ad37-ed6a5912be72","added_by":"auto","created_at":"2026-03-30 11:20:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2894900,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/04866c8e-cf51-4597-8932-51440cac9c1a.pdf"},{"id":105408405,"identity":"364bafab-d9c5-43cb-bcaf-686caf7dacef","added_by":"auto","created_at":"2026-03-25 17:01:51","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17403,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1ExperienceofCOVID19ResponseinAddisAbabaCityAdministrationEthiopiaQuaitativetool.docx","url":"https://assets-eu.researchsquare.com/files/rs-8498540/v1/59ea20cdff1dae130ac94e01.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experience of COVID-19 Response in Addis Ababa City Administration, Ethiopia: a mixed-methods implementation study","fulltext":[{"header":"Background","content":"\u003cp\u003eCOVID-19 exposed structural and operational vulnerabilities of urban health systems worldwide. In sub-Saharan Africa, early concerns focused on constrained laboratory capacity, supply chain fragility, and dense urban transmission dynamics. Addis Ababa\u0026mdash;home to major transport hubs, diplomatic missions, and a heterogeneous population\u0026mdash;required rapid coordination across health and non-health sectors. Ethiopia reported its first COVID-19 case in March 2020, prompting activation of emergency governance and public health measures aligned with International Health Regulations (2005). The number of tests, admission and related outcomes from March 2020\u0026ndash;2023 showed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis study employed a mixed-methods implementation design to document and analyze the COVID-19 response of the Addis Ababa City Administration Health Bureau (AACAHB) from March 2020 to June 2023. The study was conducted across the eleven sub-cities of Addis Ababa and covered all major response pillars coordinated through the Incident Management System (IMS) and Emergency Operations Center (EOC).\u003c/p\u003e \u003cp\u003eThe mixed-methods approach was selected to capture both measurable system performance and implementation experiences, enabling a comprehensive assessment of how governance structures, operational strategies, and contextual factors shaped the urban pandemic response.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuantitative data sources and analysis\u003c/h3\u003e\n\u003cp\u003eQuantitative data were obtained from routine surveillance and programmatic databases, including COVID-19 testing records, case notifications, hospital admissions, recoveries, deaths, logistics and supply distribution records, and vaccination registries. Data were sourced from surveillance, laboratory, logistics, case management, RCCE, and vaccination pillars and compiled at city, sub-city, and facility levels.\u003c/p\u003e \u003cp\u003eDescriptive analyses were conducted to summarize trends over time, including testing volume, case positivity, admissions, mortality, and vaccination coverage. Indicators were analyzed by transmission phase relevant to reflect shifts in response strategy. Quantitative findings were used to characterize system scale-up, service continuity, and response outputs.\u003c/p\u003e\n\u003ch3\u003eQualitative data sources\u003c/h3\u003e\n\u003cp\u003eThe qualitative component consisted of key informant interviews (KIIs), desk review of operational documents, and validation workshops. KIIs were conducted with purposively selected informants who had direct involvement in planning, coordination, or implementation of the COVID-19 response.\u003c/p\u003e \u003cp\u003eThe semi-structured interview guide was developed specifically for this study based on WHO emergency response pillars and adapted to the local COVID-19 response context. The English version of the interview guide is provided as Supplementary File 1.\u003c/p\u003e \u003cp\u003eParticipants included IMS and EOC leadership, pillar leads, sub-city coordinators, frontline managers, and technical experts from surveillance, laboratory services, logistics and supply chain management, case management and IPC, RCCE, vaccination, and planning and evidence synthesis units. Informants represented both strategic and operational levels to capture system-wide and frontline perspectives.\u003c/p\u003e \u003cp\u003eEach interviewee was assigned a unique anonymized identifier (KII-01, KII-02, etc.) to preserve confidentiality while allowing traceability of themes across response pillars.\u003c/p\u003e\n\u003ch3\u003eData collection procedures\u003c/h3\u003e\n\u003cp\u003eSemi-structured interview guides were developed based on WHO emergency response pillars and adapted iteratively as the response evolved. Interviews explored preparedness, coordination mechanisms, operational adaptations, workforce experiences, community engagement, ethical dilemmas, psychosocial impacts, and lessons learned.\u003c/p\u003e \u003cp\u003eInterviews were conducted in Amharic or English, audio-recorded with informed consent, and supplemented with detailed field notes. Interviews continued until thematic saturation was achieved across pillars.\u003c/p\u003e\n\u003ch3\u003eQualitative analysis\u003c/h3\u003e\n\u003cp\u003eInterview recordings were transcribed verbatim and translated into English where necessary. A thematic approach was applied, combining deductive coding aligned with predefined response pillars and inductive coding to capture emergent issues not initially anticipated.\u003c/p\u003e \u003cp\u003eAn initial codebook was developed and refined iteratively. Two analysts independently coded transcripts, reconciled discrepancies through discussion, and grouped codes into higher-order themes reflecting governance, implementation processes, adaptations, constraints, and lived experiences of responders and communities.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eIntegration of quantitative and qualitative findings\u003c/h2\u003e \u003cp\u003eQuantitative and qualitative findings were integrated at the interpretation stage. Quantitative trends were used to contextualize qualitative narratives, while qualitative findings explained the mechanisms, challenges, and human dimensions underlying observed system performance.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was obtained from the Addis Ababa City Administration Health Bureau Research Ethics Committee. All participants provided informed consent prior to participation. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eLeadership, coordination, and governance\u003c/h2\u003e\n \u003cp\u003eEarly establishment of the Incident Management System (IMS) and Emergency Operations Center (EOC), Shows in Fig.\u0026nbsp;2, created a shared operational architecture that guided the COVID-19 response across all administrative levels. Informants described the IMS as central to role clarity, rapid decision-making, and reduction of fragmentation among response pillars.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Once the EOC was activated, everyone understood where decisions were coming from and where to report. That clarity was critical during the early chaos.\u0026rdquo; \u003cem\u003e(KII-03, EOC Coordination)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eAs transmission intensified, governance arrangements adapted to balance centralized strategic oversight with decentralized operational authority. Sub-city and woreda teams were increasingly empowered to tailor implementation to local contexts.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;We learned quickly that central control alone would not work. When cases surged, decentralization was not optional\u0026mdash;it was survival.\u0026rdquo;\u003cem\u003e(KII-07, Sub-city Lead)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThese adaptive governance processes facilitated continuity of response across multiple waves.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSurveillance and contact tracing.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSurveillance strategies evolved in response to escalating transmission and operational constraints. Initial phases emphasized exhaustive contact tracing, while later stages prioritized targeted tracing in high-risk settings such as markets, prisons, schools, and densely populated neighborhoods. The algorithm applied in the first phase showed in Fig.\u0026nbsp;3.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;At first, every contact was followed. Later, when numbers exploded, we had to trace strategically. Otherwise, the system would collapse.\u0026rdquo; \u003cem\u003e(KII-11, Surveillance Officer)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThe algorithm applied for contact tracing during phase 2 is shown in Fig.\u0026nbsp;4. Community fear, stigma, and mistrust occasionally disrupted surveillance and containment efforts, particularly following deaths or delays in test results.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;After a suspected COVID-19 death in Addis Ketema, the family buried the body before results were released. When contact tracing began, the team faced hostility and had to flee.\u0026rdquo; \u003cem\u003e(KII-14, Contact Tracing Supervisor)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThese incidents illustrate how external contextual factors shaped implementation fidelity.\u003c/p\u003e\n \u003cp\u003eFrom February 2021 onward, contact tracing and follow-up activities were reshaped from exhaustive contact tracing approach to targeted contact tracing approach. at the woreda, and facility levels and activities were decentralized at each level. The activities of contact tracing throughout the outbreak showed in Fig.\u0026nbsp;5.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eLaboratory system expansion and constraints\u003c/h2\u003e\n \u003cp\u003eLaboratory capacity expanded through decentralization and engagement of additional public and private facilities. Informants emphasized that this expansion improved access to testing and supported timely decision-making.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;When private laboratories were integrated and machines were decentralized, turnaround times improved and response decisions became faster.\u0026rdquo; \u003cem\u003e(KII-05, Laboratory Lead)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eBetween 20 March 2020 and 05 May 2023, a total of 2,731,850 laboratory tests were performed, both in Ag-RDT and in PCR, in Addis Ababa. For PCR purposes, eight public and twenty-four private RT PCR testing sites were established.\u003c/p\u003e\n \u003cp\u003eA total of 2,819 tests were performed on specimens collected from a dead body between 29 March 2021 and 1 May 2023. Among these tests, 446 (16%) were positive. The majority (99%) of the results were released in three days, while 83% were notified within one day. The positivity rate was higher in the NSL (13.2%) and Yeka (12.7%) sub cities (Fig.\u0026nbsp;6). Private health facilities contributed for 60% of tests.(Fig.\u0026nbsp;7)\u003c/p\u003e\n \u003cp\u003eDespite these gains, global shortages of reagents and consumables required continuous prioritization and operational flexibility.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eLogistics and supply chain resilience\u003c/h2\u003e\n \u003cp\u003eDespite global shortages, AACAHB mobilized procurement, donations, and local production (e.g., alcohol-based hand rub), maintained biomedical equipment, and distributed essential supplies to facilities using adaptive allocation frameworks, and distributed supplies that cost 788,384,654.79 ETB (Table\u0026nbsp;1).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eCost of pharmaceuticals and medical supplies received from different organisations in support of COVID-19 response\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003esn\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eTotal price received\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003ePharmaceuticals Supplies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e573,286,158.84 ETB\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eMedical equipment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e205,698,642.00 ETB\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eother medication( Different medicines)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e9,399,853.95 ETB\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eTotal price\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e788,384,654.79 ETB\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eBiomedical maintenance teams restored non-functional ventilators and critical devices, mitigating equipment shortages and sustaining facility functionality during peak periods.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eCase management, IPC, and health workforce experience\u003c/h2\u003e\n \u003cp\u003eFacility readiness, referral systems, and the introduction of home-based isolation and care (HBIC) reduced hospital burden and preserved capacity for severe cases.\u003c/p\u003e\n \u003cp\u003eIsolation and treatment capacity expanded alongside the introduction of home-based isolation and care, preserving hospital capacity for severe cases. Beneath these operational achievements, informants described profound personal and psychosocial strain among health workers.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;For more than a year, I lived away from my family\u0026mdash;just a few hundred meters from home. I missed funerals and all social life. When I tested positive myself, the psychological impact was worse than the physical symptoms.\u0026rdquo; \u003cem\u003e(KII-01, IMS Leadership)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eDuring peak transmission periods, illness and death among patients and colleagues further intensified emotional distress.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;By late 2020, exhaustion was everywhere. I was admitted to ICU for ten days and witnessed eight deaths around me. It was deeply distressing.\u0026rdquo; \u003cem\u003e(KII-18, Case Management Lead)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThese experiences underscore the limited integration of mental health and psychosocial support within emergency response structures.\u003c/p\u003e\n \u003cp\u003eThrough the HBIC program, over 302,000 patients were managed at home, with more than 98% recovering, reducing pressure on institutional care (Table\u0026nbsp;2, Fig.\u0026nbsp;8).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ehome isolation and care situation as of June 14/2023 in Addis Ababa.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTotal admission to HBIC\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e302, 479\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eRecovered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e297,764\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003etransfer to the treatment center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e2334\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNumber of HCWs admitted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e731\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNumber of HCWs recovered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e731\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eRisk communication and community engagement (RCCE)\u003c/h2\u003e\n \u003cp\u003eA citywide RCCE strategy leveraged Family Health Teams, mass media, and community networks to address misinformation, promote preventive behaviors, and support vaccination uptake.\u003c/p\u003e\n \u003cp\u003eRisk communication strategies relied heavily on trusted local actors, including Family Health Teams, religious leaders, and community volunteers. Informants emphasized that trust, rather than message volume, determined uptake.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;People listened more to health workers and community leaders they knew than to national announcements.\u0026rdquo; \u003cem\u003e(KII-12, RCCE Coordinator)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eMisinformation and stigma, particularly in early phases, undermined adherence to prevention measures and delayed care-seeking.\u003c/p\u003e\n \u003cp\u003eTo improve COVID-19 preventive and control strategies, the team uses engagement principles to involve the community, stakeholders (schools, workplaces), and partners. Community mobilization networks, including youth associations, volunteers, Edir ( Traditional social organization to support each other, especially during mourning), WDA (Women Development Army), condominium associations, community-based organizations, and religious leaders, are key players in the implementation of community engagement.\u003c/p\u003e\n \u003cp\u003eCommunity engagement was driven by volunteers, youth groups, and religious leaders who promoted prevention measures, vaccination, and adherence to public health directives, while providing psychosocial support. RCCE activities also reached schools and workplaces through targeted information sharing and vaccination promotion. Trends of key message dissemination plan and performance seen in Fig.\u0026nbsp;9.\u003c/p\u003e\n \u003cp\u003eEthiopia has officially launched the \u0026ldquo;No Mask No Service National Campaign\u0026rdquo; January 30/2021 as part of an effort to fight coronavirus pandemic across the country. The measure which is effective at all schools in the country is said to have a paramount importance in curbing the spread of the virus in schools thereby protecting the teaching learning process from disruption due to the pandemic. Students have been urged on the occasion to adhere to mask wearing measure out of schools to protect the community from COVID 19.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003eVaccination rollout and equity considerations\u003c/h2\u003e\n \u003cp\u003eVaccination delivery combined fixed-site services with outreach and mobile strategies to reach informal settlements and marginalized populations. Informants consistently linked improved uptake to integrated community engagement.\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Fixed sites alone could not reach informal settlements. Outreach teams and community mobilization made the difference.\u0026rdquo; \u003cem\u003e(KII-16, Vaccination Coordinator)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eVaccine hesitancy remained closely associated with misinformation, perceived risk, and trust in institutions.\u003c/p\u003e\n \u003cp\u003ePhased vaccine introduction prioritized high-risk groups, scaled fixed and outreach services, and coordinated multisectoral mobilization to improve coverage. The overall performance of the vaccination activity shown in Table\u0026nbsp;3.\u003c/p\u003e\n \u003cp\u003eTarget prioritization and registration had been supported and conducted based on the national prioritization guidelines.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Addis Ababa COVID-19 vaccination ststus ( March 13,2021-July 16,2023)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/69519_bce2c0439cd956a6/69519_custom_files/img1774442236.png\" style=\"width: 605px;\"\u003e\u003c/p\u003e\n \u003cp\u003eKey challenges included supply chain volatility, workforce burnout, misinformation, and data fragmentation. Financial constraints necessitate prioritization and partner support.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs demonstrated in the Results, across all pillars, the COVID-19 response in Addis Ababa was shaped by adaptive leadership, decentralized implementation, and sustained commitment of health workers and community actors. While operational continuity was maintained across successive waves, qualitative findings reveal the significant human, psychosocial, and ethical costs associated with prolonged emergency response in a dense urban setting.\u003c/p\u003e \u003cp\u003eThis approach is consistent with the WHO COVID-19 Strategic Preparedness and Response Plan, which emphasizes strong coordination mechanisms and adaptive governance in public health emergencies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Such institutional arrangements are particularly important in large urban settings with complex administrative structures.\u003c/p\u003e \u003cp\u003eThe governance arrangements observed in Addis Ababa also align with the requirements of the International Health Regulations (2005) and the WHO Emergency Response Framework, both of which stress timely detection, reporting, and coordinated response as core capacities for health security [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The Results show that centralized strategic oversight combined with decentralized operational implementation supported continuity of essential response functions across successive waves of the pandemic.\u003c/p\u003e \u003cp\u003e Expansion of surveillance and laboratory capacity, as reported in the Results, was guided by national policies and technical standards. The Ethiopian Public Health Institute\u0026rsquo;s national COVID-19 management handbook provided an operational framework for integrating surveillance, laboratory testing, and case management [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], while routine situation reports documented adaptive implementation at city level [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These actions addressed early concerns about Africa\u0026rsquo;s vulnerability to COVID-19 due to health system constraints and high transmission risk in urban areas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRisk communication and community engagement (RCCE) strengthened adherence to public health measures and supported vaccine uptake, consistent with WHO guidance [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Overall, the Results support evidence that early, coordinated responses in African settings yield substantial health and economic benefits [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The mixed-methods design enhanced interpretation by linking implementation processes with outcomes, in line with established methodological guidance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis mixed-methods implementation study documents the COVID-19 response in Addis Ababa and situates it within the broader experience of African urban health systems during the pandemic. The findings demonstrate that centralized emergency governance through an Incident Management System (IMS) combined with decentralized operational execution was a critical enabler of timely decision-making, partner coordination, and adaptive response. Similar governance arrangements were reported in Lagos State, Nigeria, where Emergency Operations Centers coordinated multisectoral actors and improved situational awareness, though subnational fiscal and workforce constraints remained [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In South Africa, metropolitan municipalities integrated COVID-19 command councils with disaster management structures, facilitating continuity of essential services while scaling epidemic control measures [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurveillance and laboratory decentralization were pivotal to Addis Ababa\u0026rsquo;s response. Expansion of testing capacity through public\u0026ndash;private partnerships and phased introduction of rapid antigen diagnostics reduced turnaround times and supported targeted interventions. Comparable strategies were reported in Nairobi and Johannesburg, where decentralized testing and community screening enhanced early detection and outbreak control [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Persistent fragmentation between surveillance, laboratory, and vaccination data systems mirrors challenges reported in Accra and Dar es Salaam, underscoring the need for interoperable digital platforms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRisk communication and community engagement (RCCE) emerged as a cornerstone of response effectiveness. Addis Ababa\u0026rsquo;s Family Health Team\u0026ndash;led engagement aligns with evidence from Kampala and Accra showing that trusted community intermediaries significantly improved adherence to non-pharmaceutical interventions and reduced misinformation [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Studies from Senegal and Rwanda further indicate that transparent communication strengthened public trust in government-led responses [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCase management and health system resilience were strengthened through home-based isolation and care models, reducing hospital congestion and preserving capacity for severe cases. Similar approaches were implemented in Cape Town and Casablanca with positive effects on bed availability and healthcare worker safety [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Nonetheless, workforce fatigue and psychosocial stress\u0026mdash;widely reported across African settings\u0026mdash;highlight the need for sustained investments in health worker well-being and surge staffing mechanisms [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVaccination rollout strategies benefited from phased prioritization, outreach services, and multisectoral mobilization. Evidence from Nairobi, Kigali, and Lagos indicates that mobile vaccination units and community-based delivery models improved access in urban informal settlements [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Persistent vaccine hesitancy, also observed elsewhere in Africa, emphasizes the importance of integrating RCCE with immunization planning [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, Addis Ababa\u0026rsquo;s experience reinforces regional evidence that urban pandemic preparedness requires institutionalized emergency management capacity, interoperable data systems, resilient supply chains, and sustained community engagement.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe COVID-19 response in Addis Ababa demonstrates that large, complex urban health systems in low- and middle-income countries can sustain effective pandemic control when centralized emergency governance is combined with decentralized, context-sensitive implementation. Early activation of the Incident Management System (IMS) and Emergency Operations Center (EOC) provided a coherent command structure that enabled coordination across eleven sub-cities, rapid decision-making, and adaptive management across successive epidemic waves.\u003c/p\u003e \u003cp\u003eThe response was strengthened by timely expansion of surveillance and laboratory capacity, flexible logistics and supply chain mechanisms, community-centered risk communication, and the introduction of home-based isolation and care models that preserved hospital capacity. At the same time, qualitative findings reveal the substantial human, psychosocial, and ethical costs borne by frontline responders and communities\u0026mdash;costs that are often under-recognized in emergency planning but are central to system resilience.\u003c/p\u003e \u003cp\u003eThis mixed-methods implementation study highlights that governance structures alone are insufficient without sustained investment in health workforce protection, mental health and psychosocial support, interoperable data systems, and trusted community engagement platforms. The Addis Ababa experience underscores the importance of institutionalizing emergency preparedness capacities beyond crisis periods, embedding IMS/EOC functions within routine health system governance, and strengthening urban health resilience in anticipation of future public health emergencies.\u003c/p\u003e \u003cp\u003eLessons from Addis Ababa are transferable to other rapidly growing cities facing similar demographic density, informality, and health system constraints. Building resilient urban health systems will require not only technical preparedness, but also long-term commitment to people-centered implementation, equity, and adaptive governance.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproved by Addis Ababa Health Bureau Research Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions: DD conceived the study and led implementation; MA led analysis and drafting. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge AACAHB staff, sub-city teams, health facilities, community actors, and partners for their contributions.\u003c/p\u003e\n\u003cp\u003eWe would like to take a moment to acknowledge the hard work and dedication of the Addis Ababa Health Bureau, and specifically the Addis Ababa Public Health Research and Emergency Management (AAPHREM) Directorate. Their commitment to excellence in public health emergency practice, stakeholders including non-government organizations support, and the community active participation, and the technical team attention to detail has resulted in successful COVID-19 pandemic management that lead to successful control of the pandemic with limited health, social, and economic impacts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAvailable from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO COVID-19 Strategic Preparedness and Response Plan. Geneva: WHO; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. International Health Regulations. (2005). 3rd ed. Geneva: WHO; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Emergency Response Framework. 2nd ed. Geneva: WHO; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEthiopian Public Health Institute. National Comprehensive COVID-19 Management Handbook. Addis Ababa: EPHI; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAddis Ababa Health Bureau. COVID-19 Situation Reports (2020\u0026ndash;2023). Addis Ababa: AACAHB; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 3rd ed. Thousand Oaks: Sage; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans DK, Goldstein M, Popova A. Health, and economic benefits of early COVID-19 response in Africa. BMJ Glob Health. 2020;5:e003069.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl-Sadr WM, Justman J. Africa in the path of COVID-19. 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Afr J Prim Health Care Fam Med. 2022;14:e1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfolabi AA, Ilesanmi OS. Risk communication during COVID-19 in Africa. Pan Afr Med J. 2021;38:152.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtaguba JE. COVID-19, community trust and public health messaging in Africa. Health Econ Rev. 2020;10:28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeck SM, et al. Community perceptions of COVID-19 in Senegal. BMC Public Health. 2021;21:1234.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBinagwaho A, et al. Rwanda\u0026rsquo;s COVID-19 response: governance and trust. Lancet. 2020;395:350.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan J, et al. Hospital surge capacity and home-based care models in Cape Town. S Afr Med J. 2021;111:1130\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Aouad R, et al. COVID-19 case management strategies in Morocco. East Mediterr Health J. 2021;27:549\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaukat N, et al. Physical and mental health impacts of COVID-19 on healthcare workers. Int J Environ Res Public Health. 2020;17:3883.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTemsah MH, et al. Burnout among healthcare workers during COVID-19. PLoS ONE. 2020;15:e0239454.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarasa E, et al. COVID-19 vaccine delivery strategies in Kenya. BMJ Glob Health. 2022;7:e009019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUwizeye G, et al. Equity-focused vaccination rollout in Rwanda. Vaccines. 2022;10:1354.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassan AO, et al. Mobile vaccination units in Lagos informal settlements. Vaccine. 2023;41:1280\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSallam M. COVID-19 vaccine hesitancy worldwide: systematic review. Vaccines. 2021;9:160.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary. file 1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStudy Title. Experience of COVID-19 Response in Addis Ababa City Administration, Ethiopia.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePurpose. To explore implementation experiences, challenges, adaptations, and lessons learned from the COVID-19 response, aligned with WHO emergency response pillars.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSemi-Structured Interview Guide.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, Public health emergency, Incident Management System, Emergency Operations Center, Urban health, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-8498540/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8498540/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUrban centers in low- and middle-income countries faced substantial operational challenges during the COVID-19 pandemic. Addis Ababa, Ethiopia\u0026rsquo;s political and economic hub, implemented a comprehensive, multisectoral response coordinated through an Incident Management System (IMS) and Emergency Operations Center (EOC).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a mixed-methods implementation study synthesizing routine surveillance and programmatic data (March 2020\u0026ndash;June 2023), policy and operational documents, and key informant interviews across surveillance, laboratory, logistics, case management, risk communication and community engagement (RCCE), and vaccination pillars. Quantitative indicators were descriptively analyzed; qualitative data were thematically analyzed and triangulated. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAddis Ababa expanded surveillance and laboratory capacity through decentralization, scaled contact tracing, implemented home-based isolation and care, strengthened infection prevention and control, mobilized logistics and supply chains amid global shortages, and achieved high vaccination coverage through phased roll-out. Governance via IMS/EOC enabled coordination across eleven sub-cities and partners. Major challenges included supply chain disruptions, workforce fatigue, misinformation, and data integration constraints. Adaptive strategies\u0026mdash;task force governance, community engagement via Family Health Teams, and evidence-informed decision-making\u0026mdash;mitigated system strain.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA centralized IMS/EOC with decentralized implementation, strong RCCE, and flexible logistics were pivotal to sustaining urban pandemic response. Institutionalizing emergency management capacity and investing in data systems are critical for future preparedness.\u003c/p\u003e","manuscriptTitle":"Experience of COVID-19 Response in Addis Ababa City Administration, Ethiopia: a mixed-methods implementation study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 17:01:45","doi":"10.21203/rs.3.rs-8498540/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-20T05:01:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131385848299280769002384253700531110543","date":"2026-02-14T12:36:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T14:43:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-03T07:54:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-12T05:26:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-09T12:35:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-09T12:23:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"87afc325-e36f-447e-8b8d-8431c5b03f3b","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T17:01:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 17:01:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8498540","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8498540","identity":"rs-8498540","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}