Health system resilience in Ethiopia’s Tigray region


Partners: Queen Margaret University, Mekelle University (Ethiopia) and Tigray Health Research Institute (Ethiopia) [links open new tabs]


Over the last 50 years, the Tigray Region in Northern Ethiopia has been affected by three prolonged catastrophic wars: between 1974 and 1991, 1998 and 2000, and most recently in 2020-22. The conflict between Tigray forces led by the Tigray People Liberation Front on one side, and the allied Ethiopian National Defence Forces, Amhara regional forces and Eritrean Defence Forces on the other side has led to the collapse of what once was one of the better performing health systems in Ethiopia. Facilities were destroyed and looted, health workers were killed, abducted or fled, and as a result, health indicators such as child and maternal mortality plummeted.


On November 2nd, 2022, the conflicting parties reached an agreement for a permanent cessation of hostilities, which opened the door to the possibility of the restoration of the constitutional territory of Tigray and of federal authority in the region and the establishment of a second interim government in Tigray, supported by both sides. As the new interim government is considered legitimate and accepted by both parties, the reconstruction of the region could start (humanitarian phase), including for the health sector, in collaboration between the Ministry of Health of Ethiopia, the regional health bureau and international organisations including the WHO, under the Health Cluster coordination. The humanitarian phase as defined by the Inter Agency Standing Committee (IASC) ended in Tigray in January 2024, when the early recovery phase began, with further responsibilities transferred to local governmental administrative entities.


This study

This study aims to explore the resilience of the health system in Tigray, using a longitudinal approach covering key phases in relation to the recent conflict, and comparing the situation of the health system (i) before the 2020 conflict, (ii) immediately after the conflict during the humanitarian phase (November 2022 to January 2024) and (iii) in the early recovery phase from January 2024 – the latter with a prospective approach. The study will look at the broad health system, including its hardware elements, but also the software (intangible) elements and how the different elements connect. This in turn will support the deployment of existing resilience structures and skills in a supportive way to ensure progress towards a responsive, effective, inclusive, gender-equitable and sustainable health system.


Aims and research questions

Specifically, the study will aim to:

1. Map the health system in relation to its key elements and the resilience nodes and pathways at three critical points in time.
2. Compare the mappings to understand how the system has changed over time, and how legacies and resilience capacities in previous periods have supported (or hindered) such changes (absorptions, adaptations and transformations) which might have allowed continuity of service delivery and/or the rebuilding of the health system.
3. Draw lessons on how resilience capacities found in the health system can be deployed and supported in the recovery phase for the reconstruction of the health system


Research questions are:

1) What was the situation/state of the health system (its elements, the “resilience nodes” and pathways) in each of the three key periods?
2a) Based on the three mappings, how has the health system and its elements changed over time during conflict and early recovery? How has the system absorbed, adapted, transformed over time?
2b) Which elements of the health system and which resilience nodes/pathways were most affected, and which kept working (at some level), thus identifying resilience capacities? How did legacies from previous capacities (skills, structures, etc.) contribute to longer-term resilience?
3) How can existing resilience capacities be deployed and supported during and after conflict for the strengthening of the health system?


This study is expected to run until March 2025


Image: Nurse checks 16 months old Daniel Hagos, using respiratory monitor as his mother Girmanesh Hagos, 20, watches – via Flickr. [opens new tab] CC BY-NC-ND 2.0 DEED


"ReBUILD for Resilience brings together partners to share experiences, to discuss our contexts, and to create an appropriate model that helps build resilience in health systems across the country and beyond"

Sushil Baral, HERD International