Safe Surgery for All: Early Lessons from Implementing a National Government‐Driven Surgical Plan in Ethiopia

Abstract

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.

Global surgery and the sustainable development goals

“…Baseline assessment for Zambia's NSOAP led to plans to increase its workforce from 1·1 to 3 surgery, obstetrics and anaesthesia providers per 100 000 population by 2021. In Ethiopia, a national Surgical Workforce Expansion Plan and Anaesthesia Roadmap was developed in close partnership with the College of Surgeons of East, Central and Southern Africa to address training of specialists, continuing education and task‐shifting programmes.…”

“…Ethiopia's baseline data collection revealed that, of the surgical facilities assessed, 72 per cent consistently lacked running water, 59 per cent had intermittent electricity and 33 per cent did not have a reliable oxygen supply. To address these gaps, the Ministry of Health allocated a budget for the construction and renovation of 370 operating rooms, and partnered with Safe Surgery 2020 to construct new oxygen plants. The development of a NSOAP for the expansion of surgical services is an innovative approach to surgical care, as it fosters local advances and opens new markets to promote the expansion of industry.…”

“…A core element of Ethiopia's NSOAP was the engagement of a wide range of stakeholders from policy‐makers to clinicians and funders. To supply oxygen reliably, a public–private partnership was established to build and maintain oxygen plants as part of Ethiopia's National Medical Oxygen and Pulse Oximetry Scale Up Road Map. Another key partnership in Ethiopia was established between the Ministry of Health, PEPFAR (the US President's Emergency Plan for AIDS Relief), local colleges, universities and the GE Foundation to train biomedical technicians in repair and maintenance of equipment required for provision of essential surgical procedures.…”

The Situation of Safe Surgery and Anaesthesia in Tanzania: A Systematic Review

“…Two broad areas of focus for improving financing of surgical systems in Tanzania include increasing financial resource allocation to SOA care and implementing strategies to reduce catastrophic and impoverishing expenditure Procedures done in an operating theatre, per 100,000 population per year; 2 number of specialists surgical, anaesthesia, obstetric physicians who are working, per 100,000 population; 3 proportion of the population that can access, within 2 h, a facility that can do the Bellwether procedures; 4 proportion of households protected against catastrophic expenditure from direct out-of-pocket payments for surgical and anaesthesia care; 5 proportion of households protected against impoverishment from direct out-of-pocket payments for surgical and anaesthesia care; 6 all-cause death rate prior to discharge among patients who have undergone a procedure in an operating theatre, divided by the total number of procedures World J Surg (2019) 43: 24-35 31 to patients. Accordingly, the NSOAP finance section prioritizes the tracking of national budgetary allocations to surgical services including systemic and direct costs for providing surgical care as part of the national health account.…”

Enhanced Recovery After Surgery for Low‐ and Middle‐Income Countries

“…Led by efforts at the World Health Organization (WHO), the scale up to 44 basic surgeries and safe anesthesia is underway, and in fact two Africa countries have proposed national surgical plans for the process [5,6]. As proposed by the Lancet Commission on Global Surgery and the WHO, this is an opportunity for tracking and improving outcomes, and initiating quality programs early in the scale up processes.…”