Implementation of acute flaccid paralysis surveillance for polio eradication in Ethiopia: a qualitative study

Ethiopia has implemented acute flaccid paralysis (AFP) surveillance for nearly three decades as a core polio eradication strategy, yet remains at risk of outbreaks, particularly in pastoralist and conflict-affected areas. As Global Polio Eradication Initiative support declines, understanding factors affecting AFP surveillance and sustainability is critical. This study assessed facilitators, barriers, and adaptive strategies influencing AFP surveillance implementation in Ethiopia. A qualitative study using semi-structured interviews was conducted with 43 participants who had been involved in AFP surveillance for at least 12 months between 1996 and 2018. Guided by the Consolidated Framework for Implementation Research, participants were purposively chosen from the Ministry of Health, regional health bureaus, zonal and district health offices, and included surveillance officers, program managers, and frontline health workers from governmental and partner organizations. Data were analyzed thematically using deductive and inductive approaches in NVivo version 12. AFP surveillance implementation in Ethiopia was influenced by multilevel facilitators and barriers. Strong leadership, organizational structures, and partnerships with global and community actors supported coordination and resource mobilization. Community-based networks, including local volunteers and motivated health workers enhanced case detection and reporting in hard-to-reach areas. However, performance was constrained by high staff turnover, logistical challenges, limited subnational resources, weak supervision, and socio-cultural. Geographic inaccessibility and insecurity further limited implementation. Frontline health workers and volunteers used various adaptive strategies such as community engagement, informal reporting, and context-specific logistical solutions, to sustain surveillance activities. Continued reliance on external support posed a concern for long-term sustainability. Strong organizational systems and community engagement can sustain AFP surveillance in resource-limited settings. However, declining external support is a concern for sustainability. Integrating AFP surveillance into broader health systems, increasing domestic investment, and strengthening community-based approaches are essential for long-term resilience.