{ "background": "District hospitals in Ethiopia are critical nodes in the national health system, yet their operational reliability is often compromised. Randomised field trials (RFTs) have been increasingly employed to evaluate interventions aimed at improving system performance, but the methodological rigour and consistency of these studies have not been systematically appraised.", "purpose and objectives": "This meta-analysis aims to critically evaluate the methodological quality of RFTs assessing system reliability in Ethiopian district hospitals, identifying common design strengths, limitations, and reporting practices to inform future research standards.", "methodology": "We conducted a systematic search of multiple databases for published and grey literature. Eligible studies were RFTs with a primary outcome of system reliability (e.g., equipment uptime, protocol adherence, service continuity). Methodological quality was assessed using a modified Cochrane Risk of Bias tool and a bespoke checklist for field trial context. Quantitative synthesis used a random-effects meta-regression model: $\\thetai = \\mu + \\beta Xi + \\epsiloni$, where $\\thetai$ is the standardised effect size and $X_i$ a vector of methodological covariates. Inference was based on 95% confidence intervals derived from robust variance estimation.", "findings": "Of 37 included trials, a significant majority (78%, 95% CI: 68 to 86) exhibited high risk of bias in blinding of participants and personnel. Meta-regression indicated that trials employing a cluster-randomised design reported, on average, 0.35 standard deviations lower effect sizes (p<0.05) than individually randomised trials, suggesting potential for overestimation in the latter. Incomplete reporting of sample size calculations was a pervasive theme.", "conclusion": "The evidence base from RFTs on hospital system reliability is substantively limited by recurrent methodological weaknesses, particularly in blinding and statistical power, which may bias reported intervention effects.", "recommendations": "Future trials must prioritise explicit reporting of randomisation and blinding procedures, adopt cluster designs where appropriate, and