Recognizing the unmet need for surgical care in Ethiopia, the Federal Ministry of Health (FMOH) has pioneered innovative methodologies for surgical system development with Saving Lives through Safe Surgery (SaLTS). SaLTS is a national flagship initiative designed to improve access to safe, essential and emergency surgical and anaesthesia care across all levels of the healthcare system. Sustained commitment from the FMOH and their recruitment of implementing partners has led to notable accomplishments across the breadth of the surgical system, including but not limited to: (1) Leadership, management and governance-a nationally scaled surgical leadership and mentorship programme, (2) Infrastructure-operating room construction and oxygen delivery plan, (3) Supplies and logistics-a national essential surgical procedure and equipment list, (4) Human resource development-a Surgical Workforce Expansion Plan and Anaesthesia National Roadmap, (5) Advocacy and partnership-strong FMOH partnership with international organizations, including GE Foundation's SafeSurgery2020 initiative, (6) Innovation-facility-driven identification of problems and solutions, (7) Quality of surgical and anaesthesia care service delivery-a national peri-operative guideline and WHO Surgical Safety Checklist implementation, and (8) Monitoring and evaluation-a comprehensive plan for short-term and long-term assessment of surgical quality and capacity. As Ethiopia progresses with its commitment to prioritize surgery within its Health Sector Transformation Plan, disseminating the process and outcomes of the SaLTS initiative will inform other countries on successful national implementation strategies. The following article describes the process by which the Ethiopian FMOH established surgical system reform and the preliminary results of implementation across these eight pillars.

ProblemMaternal and neonatal mortality remains high in low- and middle-income countries, with poor quality of intrapartum care as a barrier to further progress.ApproachWe developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intrapartum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services.Local settingEthiopia has invested in hospital quality improvement for more than a decade and this tool was integrated into existing quality improvement mechanisms within lead hospitals, with the potential for scale-up to all government hospitals.Relevant changesSignificant improvements in quality of intrapartum care were detected from baseline (June–July 2015) to follow-up (February–March 2016) in targeted hospitals. The overall mean quality score rose from 65.6 (standard deviation, SD: 10.5) to 91.2 (SD: 12.4) out of 110 items (P < 0.001).Lessons learntThe method was feasible, requiring a total of 3 days and two to three trained data collectors per hospital visit. It produced data that detected substantial changes made during 8 months of national hospital quality improvement efforts. With additional replication studies, this tool may be useful in other low- and middle-income countries.

Background Surgery is among the most neglected parts of healthcare systems in low‐ and middle‐income countries. Ethiopia has launched a national strategic plan to address challenges in the surgical system. This study aimed to assess surgical capacity in two Ethiopian regions to inform priority areas for improvement. Methods A mixed‐methods study was conducted using two tools adapted from the Lancet Commission's Surgical Assessment Tools: a quantitative Hospital Assessment Tool and a qualitative semistructured interview tool. Fifteen hospitals selected by the Federal Ministry of Health were surveyed in the Tigray and Amhara regions to assess the surgical system across five domains: service delivery, infrastructure, workforce, information management and financing. Results Service delivery was low across hospitals with a mean(s.d.) of 5(6) surgical cases per week and a narrow range of procedures performed. Hospitals reported varying availability of basic infrastructure, including constant availability of electricity (9 of 15) and running water (5 of 15). Unavailable or broken diagnostic equipment was also common. The majority of surgical and anaesthesia services were provided by non‐physician clinicians, with little continuing education available. All hospitals tracked patient‐level data regularly and eight of 15 hospitals reported surgical volume data during the assessment, but research activities were limited. Hospital financing specified for surgery was rare and the majority of patients must pay out of pocket for care. Conclusion Results from this study will inform programmes to simultaneously improve each of the health system domains in Ethiopia; this is required if better access to and quality of surgery, anaesthesia and obstetric services are to be achieved.

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