Ophthalmic policy implementation in Ethiopia: barriers and enablers from a mixed-methods stakeholder study

Vision impairment remains a major public health challenge in Ethiopia. Although national eye health strategies are aligned with global initiatives, persistent gaps exist between policy intent and service delivery. This study examined the barriers and enablers influencing the implementation of ophthalmic policy from the perspectives of key stakeholders.

A nationwide mixed-methods survey was conducted between June and August 2025 across nine regions of Ethiopia. Of 270 invited participants, 221 responded (81.9%), including ophthalmic professionals (n = 118), patients (n = 82), policymakers (n = 9), NGO/INGO representatives (n = 8), and international experts (n = 4). Quantitative data were analysed using descriptive statistics, bivariate analyses, and regression models, while qualitative data were thematically analysed and integrated using a convergent mixed-methods approach.

Overall service satisfaction was high, at 93.8% (95% CI: 90.1-96.1). Patients residing within 5 km of a facility were significantly more likely to report satisfaction compared with those travelling more than 20 km (OR = 18.0; 95% CI: 1.4-236.1). No demographic variables significantly predicted perceived policy implementation in ordinal regression analyses, despite acceptable model fit. Qualitative findings identified chronic funding constraints, workforce shortages, and donor dependency as major implementation barriers, while policy alignment and professional commitment emerged as key enabling factors.

Ophthalmic policy implementation in Ethiopia is primarily driven by systemic capacity and geographic access, rather than individual professional characteristics. Strengthening sustainable financing, improving workforce distribution, and expanding locally accessible services are critical to narrowing policy-practice gaps and advancing equitable eye health in Ethiopia and similar low- and middle-income settings.