National Surgical Care Strategic Plan:

Saving Lives through Safe Surgery II

(SaLTS II)

2021–2025
 INTRODUCTION

1.1 Background
Globally, around five billion people lack access to safe, affordable, and timely emergency and
essential surgical care (EESC), leading to preventable mortality and morbidity and avoidable
disability and deformity. In 2005, as part of its newly launched initiative to increase access to EESC,
the World Health Organization (WHO) published guidelines for cost-effective surgical care
interventions, and released a situational analysis tool to assess the availability of EESC and needed
inputs at the health facility level in low- and middle-income countries (LMICs). The initiative helped
to galvanize global commitment, successfully advocated for the inclusion of EESC into universal
health coverage packages, and convened member countries to prioritize surgical care in their national
health strategy plans.1,2
Improving delivery of EESC in LMICs will require measuring access in terms of capability, capacity,
timeliness, safety, and affordability. To support this effort, the Lancet Commission on Global Surgery
(LCoGS) identified the following targets to be achieved by 2030: (1) 80% coverage of essential
surgical and anesthesia services per country, (2) at least 20 surgical, anesthesia, and obstetric
physicians per 100,000 population, (3) 5,000 procedures annually per 100,000 population, and (4)
100% protection against catastrophic expenditure from out-of-pocket payments for surgical and
anesthesia care.
The Saving Lives Through Safe Surgery (SaLTS) Program (2016–2020), Ethiopia’s safe surgery
strategic plan, was created to address the huge unmet need for basic surgical care services. The
proposed surgical care strategy is well aligned with global and local recommendations, including
recommendations by the WHO and Government of Ethiopia’s Health Sector Transformation Plan
(HSTP) and quality strategy. In line with the country’s vision to assure quality and equity of health
care, and as part of recognizing the key role that EESC can play in meeting universal health coverage
goals, Ethiopia prioritized surgical and anesthesia services as part of the comprehensive primary

1
World Health Organization (WHO). Surgical care systems strengthening: developing national
surgical, obstetric and anesthesia plans. Geneva, 2017;33–38. ISBN 978-92-4-151224-4.
2
Spiegel DA, Abdullah F, Price RR, Gosselin RA, Bickler SW. World Health Organization Global
Initiative for Emergency and Essential Surgical Care: 2011 and beyond. World Journal of Surgery.
2013 Jul; 37(7):1462–1469.
3
Ministry of Health of Ethiopia. National Safe Surgery Strategic Plan: Saving Lives Through Safe
Surgery (SaLTS) Strategic Plan, 2016–2020. Addis Ababa, Ethiopia, 2016.
4
Tadesse H, Sibhatu M, Maina E, Bari S, Reynolds C, Richards K, Garringer K. Savings Lives
Through Safe Surgery in Ethiopia: Project Implementation Manual. Addis Ababa, Ethiopia, 2019.
health care packages. The SaLTS II program will remain the national flagship initiative, and will
galvanize support from health leaders and other key stakeholders involved in expanding access to safe
surgical care in Ethiopia. 3,4
This strategy has been instrumental in defining and standardizing the minimum care packages needed
to expand emergency and essential surgical and anesthesia care. The eight intervention pillars
described in the strategic plan are: (1) leadership, management, and governance, (2) infrastructure
development, (3) supplies and logistics management, (4) human resource development, (5) advocacy
and partnership, (6) innovation in problem-solving, (7) quality and safety across the perioperative
continuum of surgical and anesthesia care, and (8) monitoring and evaluation.5
Following the call for action, in 2015, the LCoGS formulated six metrics to enable countries to
measure their surgical and anesthesia care delivery (Table 1). These indicators were subsequently
accepted by the World Bank for inclusion in the World Development Indicators. These surgical and
anesthesia care delivery outcome measurement indicators have also been included in the WHO 100
Core Health Indicators. The indicators will be crucial for Ethiopia to measure outcomes of surgical
and anesthesia care delivery separately from other indicators, and can be tailored to the Ethiopian
context.
Table 1: Surgical and anesthesia care delivery indicators

Indicator Target

Access to timely essential A minimum of 80% coverage of essential surgical and

surgery anesthesia services per country by 2030
Specialist surgical 100% of countries with at least 20 surgical, anesthesia, and
workforce density obstetric physicians per 100,000 population by 2030
5,000 procedures annually per 100,000 population by 2030 as a
Surgical volume
measure of met need for surgical and anesthesia care
Perioperative mortality rate 80% of countries by 2020 and 100% of countries by 2030
(POMR) tracking POMR
Protection against 100% protection against impoverishment from out-of-pocket
impoverishing expenditure payments for surgical and anesthesia care by 2030

5
Burssa D, Teshome A, Iverson K, Ahearn O, Ashengo T, Barash D, et al. Safe surgery for all: Early lessons from
implementing a national government-driven surgical plan in Ethiopia. World Journal of Surgery. 2017 Dec; 41(12):3038–
3045.
1.2 Rational and scope of the strategic Plan:
Provision of essential surgical care is among the most cost-effective of all health interventions and
would avert about 1.5 million deaths a year, or 6%–7% of all preventable deaths in LMICs. In
general, the large burden of surgical disorders, cost-effectiveness of essential surgery, and strong
public demand for surgical care suggest that financing essential surgical care along the path to
universal health coverage is a wise decision. It would efficiently and equitably provide health benefits
and financial protection and would contribute to the development of stronger health systems and the
provision of high-quality health care in the nation.
The previous SaLTS strategy focused only on emergency and essential surgical services. However, a
recent estimated cost analysis by the MoH demonstrated that the cost of annual outflow from Ethiopia
due to medical tourism exceeds US$100 million and implies a high degree of opportunity cost that
could be saved and instead brought into the country by making high-end tertiary health services
available. Thus, it is more than justifiable to include certain specialty and subspecialty surgeries to be
delivered at the community level in selected health care facilities based on feasibility, which can
result in a significant economic gain for the country
 Ethiopian Context
2.1 Geography and Climate
Ethiopia is located in the North-Eastern part of Africa, also known as the Horn of Africa. It is
bordered by Sudan and South Sudan on the west, Eritrea and Djibouti on the northeast, Somalia
on the east and southeast, and Kenya on the south. The country occupies an area of 1.1 million
square kilometers (sq. km) and bodies of water occupy 7,444 sq. km. Ethiopia is a country with
rich geographical diversity. It consists of rugged mountains, flat-topped plateaus, deep gorges,
and river valleys. Its erosion, volcanic eruptions, and tectonic movements over the ages have
contributed to the nation’s diverse topography. More than half of the geographic area of the
country lies 1,500 meters (m) above sea level. The highest altitude is at Ras Dashen (4,620 m
above sea level), and the lowest is at Danakil (Dallol) Depression (148 m below sea level).
Ethiopia’s climate is naturally conditioned and varies greatly across its territories. It comprises
all types of climate conditions, temperate on the plateau and hot in the lowlands. Although the
country lies within the tropics, its proximity to the equator is counterbalanced by the elevation of
the land. The climate in the greater part of Ethiopia is temperate; however, in places below
1,200 m (3,937 feet), the conditions are tropical. In Addis Ababa, the country’s capital, elevation
ranges from 2,200 to 2,600 m (7,218 to 8,530 feet) and the temperature is typically between
26°C (78.8°F) and 4°C (39.2°F). The weather is usually sunny and dry, but the short (belg) rains
occur from February to April and the large (meher) rains from mid-June to mid-September.

2.2 Demographic Profile

Ethiopia is the second most populous country in Africa, following Nigeria, with an estimated
population of 110 million people. It is growing fast as compared to the last national census in
2007. This significant growth in the country’s population is also directly related to the demand
for national medical care, including surgical care. 6

6
Ministry of Health of Ethiopia. Health sector transformation plan II. July 2020.

5
2.3 Conceptual Framework:
The surgical care concept framework illustrates the key system inputs, processes, and possible
outcomes and impacts perceived to be achievable by implementing this strategic plan in
Ethiopia. It uses the six-plus WHO health systems building blocks as input and the seven
interventions pillars as the process achieve the desired outcome (reduce surgical related
morbidity and mortality) in Ethiopia

outcome Reduced mortality and morbidity

innovation, technology, learning, and advocacy

innovation, technology, learning, and advocacy

intermediate
result Equitability accessible, effective, safe, efficient,
and people-centered surgical care

Process intervention aiming at improving surgical care

provision

health information
Foundations health workforce
service delivery
leadership and

infrastructure
Governance

community
ownership
healthcare
financing

Fig 1. A conceptual framework for strategy development

Table 3.1 key domains of the framework with description

Domain Description
Reduced Mortality and
morbidity The reduction of death and morbidity due to surgery-related illness
Equitable access to the essential surgical and anesthesia care regardless
Equitable access of any background like geography, ethnicity, religion…

Effective care Evidence-based care consistent with current professional knowledge

Efficient Reduces waste
Safe Reduce Surgical care-related harm
An approach to care that consciously adopts the perspectives of
individuals, families, and communities, and sees them as participants as
well as beneficiaries of trusted health systems that respond to their
People-centered needs and preferences in human and holistic ways

6
 A well-structured, effective, and accountable leadership and
Leadership and governance management system at all level of the health care system

Health workforce Well trained surgical workforce with a professional mix

the function of a health system is concerned with the mobilization,
accumulation, and allocation of money to cover the health needs of the
Healthcare financing people, individually and collectively, in the health system…
Health infrastructure relates to all the physical infrastructure, non-
medical equipment, transport, and technology infrastructure (including
ICT [Information and Communication Technologies]) required for
Infrastructure effective delivery of services.

community ownership

7
 Situational Analysis:
Policymakers and strategic plan implementers use situational analysis to analyze the internal and
external environments to understand the capabilities, service consumers, and overall environment
in the implementation of SaLTS II. The situational analysis employs the Strengths, Weaknesses,
Opportunities, and Threats (SWOT) method, using strengths and weaknesses to evaluate the
internal situation and opportunities, and threats to look for external factors that can influence the
implementation of SaLTS II either directly or indirectly. The SWOT analysis addresses the six
health systems building blocks plus.

3.1 Preliminary Evaluation result of the First five year 2015/16 -2020/21 National Safe
Surgical Care Strategy and the Saving Lives through Safe Surgery (SaLTS) Program
in Ethiopia.

3.1.1 Findings
This study showed inadequate access to surgical services, and noticeable variation were
illustrated with level of health facilities and administrative regions. Majority of the surgical
admissions and procedures were illustrated in Amhara and Oromia regions, the most populous
Ethiopian regions, and these regions also represented two-third of the total referral outs. Lowest
referral out rate was shown in Addis Ababa city administration. Most of the referral out reported
are related to scarce availability of skilled professional. Lack of equipment/instrument was the
second most common reason for referral outs in most of the Ethiopian regions.
At primary hospitals, Electric power interruption and CSR/Laundry dysfunction were the
leading cause of emergency and essential surgical care interruption. Majority of the emergency
and essential surgical care interruption at Generalized hospitals anf Health center OR Blocks
were related to Equipment dysfunction and Electric power interruption .
Clients need to travel sizably long distance to access surgical services, up to 303.1 km to acess
the specialized hospitals . The longest traveling distance to access primary to specialized
hospitals was reported in Tigray region, while the shortest (for specialized hospitals) was shown
in Harari Region and an averge of 9.3 km travel to acess health centers with OR blockes .
Health facilities, specially of the Tigray and Oromia Regions and Diredawa city administration,
had shortage of management guidelines for emergency care and surgery, obstetrics and
anesthesia care. Inadequate utilization of surgical safety checklist was shown in most of the
facilities The average rate of SSC utilization is found to be highest in specialized and general
hospitals (80% and 79% respectively), this rate is closely followed by primary hospitals where

8
the rate of SSC utilization was observed to be 71%. Private hospitals have the lowest rate (26%)
whereas in health center OR blocks the rate of utilization of SSC is somewhat higher at 59%.
Majority of the surgical site infections and longest preadmission waiting time were reported at
specialized hospitals, while the lowest infection rate and shortest preadmission waiting time was
shown at private hospitals. The longest preadmission waiting time (about three days) was noted
in Addis Ababa city administration and Oromia Region. Private hospitals had relatively higher
cancelation rate for scheduled surgical cases. Nationally Medical reasons (29.14%) and lack of
blood and blood products (21.71%) are the cited to be the most common reasons nationally for
cancelation of surgical cases after being scheduled.
No anesthesia adverse outcomes were reported at health centers and private hospitals.
Significantly low average anesthesia adverse outcomes were illustrated at primary, generalized
and specialized hospitals.All health care facilities had higher rate of delay in starting surgical
procedures. Only a quarters to a third of surgical procedures were started at the agreed/set time at
all levels of facilities,
On average the longest time difference between two consecutive elective surgeries is observed in
private hospitals (75.52 minutes) while in public specialized, general and primary hospitals the
average turnover time is found to be in similar range 40 – 40.76 minutes.
Health care facilities providing surgical services were poorly staffed and equipped with relevant
human resources and equipment/supplies, respectively. Sizable variations in readiness of
facilities was also revealed among administrative regions and levels of facilities. Government
hospitals had lower number of surgeons, especially primary hospitals had considerably lower
number of obstetrician, compared to private hospitals. Despite the largest reported surgical
admission and procedures, Amhara and Oromia Regions had lower staffing profile for
obstetricians, surgeons and anesthesiologists/anesthesia. These regions were mainly staffed with
qualified IESO. Whereas, Addis Ababa city administration had better number of obstetricians,
surgeons and anesthesiologists/anesthesia. Most of the health care facilities did not monitor
patient’s re-admission. Substantial proportion of the health facilities, specially of the specialized
hospitals and health centers, did not have consistent/regular availability of emergency and
essential surgical care equipment and supplies.

9
3.1.2 Recommendations
Evaluation results suggest sizable gaps in readiness of health facilities for surgical services, and
low access and utilization of surgical services and safety procedures. Therefore, it is highly
valuable to strengthen surgical services of the health facilities with relevant human resource and
equipment’s/supplies. Findings also indicated the importance of enhancing availability and
utilization surgical safety supplies to reduce adverse incidents of surgeries/anesthesia or enhance
surgical efficiency at large. Finally, increasing access to surgical services and reducing delay in
admission and initiation of surgical procedures will help to increase utilization of the respective
services.
This study has explored the experiences of surgery service beneficiaries and service providers
through exit, in-depth and key informant interviews. Based on the result; it was reported that
accessible service, good case management, hospitality, communication, getting equitable service
were in place. On the other hand; long waiting time, re-appointment, inadequate drugs and
laboratory services, lack of food, water supply, pajamas/gowns and toilet problems were reported
as a gaps.

Providers and key informants discussed that the SaLTS initiative was found to be very important
and has brought significant changes. It was explained that SaLTS was successful in leadership
and governance, Human resource development, monitoring and evaluation, and quality and
safety. However, limited to null change was reported by most of participants on the area of
infrastructure, supply and logistics, innovation and advocacy. Lack of responsible body who own
the program and lack of resources were articulate as challenge and gap of the program by most
of the participants. Using the standard checklist and making the surgery service more accessible,
reducing surgical site infection and serving much number of patients, reduction in cancelation of
surgery appointments, decrease in mortality, and patient safety were found to be major benefits
and lessons of the SaLTS program. Getting owner to the program, capacity building, incentive to
professionals, and provision of supply, improving the infrastructure, engaging stakeholders,
strengthening Monitoring and evaluation, improving recording and documentation, and
budgeting to the program are some of the major areas that demand improvement.

10
Table 3: SWOT table

LEADERSHIP AND GOVERNANCE

Strengths Weaknesses
 Aligned with Policies and  No structural or functional ownership of surgery and
Strategies – Specialty road anesthesia in all administrative and facility settings
map, EHSP, HTSP II  No clear and accountable governance and management
(surgical service, structure for surgical and anesthesia care at all levels
emergency, and critical  Inadequate coordination, harmony, and synchrony
care), and APTS between agencies, directorates, regions, and health
(consumables), EHAQ facilities
(human resource  Poor public-private partnership
redistribution), EPHAQ,  Poor leadership and management skills
EHSTG, and HSTQ  Lack of evidence-based decision-making process
 Budget allocation  Low surgical and anesthesia policy Index
 Partnership enhancement  Poor awareness of leadership on the significance of
 Actions for surgery and anesthesia care/service
standardization—standard  No leadership and managerial accountability
 Regulation (facility  Essential surgical and anesthesia care are not classified as
standard, licensing, and primary health care
accreditation)  Donor-dependent program design, resource, and funding
 Improved integrated allocation
supportive supervision  Inadequate focus on streamlined planning and
practice implementation among FMOH directorates and agencies,
partners, and regions
 Low involvement of patients in decision-
making/leadership level
 Inequity in leading and implementation capacity among
regions and health facilities
 Weak implementation capacities among agencies, the
FMOH, and regional health bureaus (RHBs)
 Lack of structural review and adjustment along with the
strategic plan
HEALTH WORKFORCE

Strengths Weaknesses
 Increased focus on CPD  Inadequate surgical and anesthesia workforce with a wide
 Growth of the health gap in the global indicator of surgical capacity per
workforce population
 Absence of fair compensation and incentive package
 Uneven distribution of the surgical and anesthesia
workforce

11
  No well-justified and need-based launch of programs
 Lack of need-based human resource development strategy
 Inadequate budget allocation to support the surgical
workforce at the facility level
 Lack of need-based human resource structure and
allocation
 Poor retention plan and mechanism
 Limited capacity to own and lead some program areas at
the national level
 Poor provider attitude and low commitment of various
stakeholders
 High attrition rate and absence of human resources
motivation and retention strategy
 Weak institutional knowledge management
 Weak knowledge generation and use at the national level
 Lack of sustainable licensing and relicensing process
 Surgical workforce is produced without a clear career path
or adequate training
 Poor staff well-being and burnout management system for
the surgical Frustration and grievances among health
professionals
SERVICE DELIVERY
Strength Weakness
 Expanding and  Inequity of access to surgical and anesthesia care
decentralizing the blood  No/poor performance-based appraisals
bank service  No standardized /protocol-based surgical and anesthesia
 Improving the prehospital care
ambulance service and  Lack of service readiness and community needs
referral system assessment at the facility level
 Improving diagnostic  Lack of patient-centered approach
imaging and laboratory  Accessibility of health service (cost, language, culture, or
facilities geography)
 Expanding surgical and  No established continuity of care
anesthesia care service and  No service directory
access to the public  Inadequate availability of clinical service protocols for
 Established a disaster and health facilities
emergency response team at  No standardized service assessment tools/checklists or
all levels indicators
  Current health policy is not enabling
EQUIPMENT AND SUPPLY
Strength Weakness
 Existence of authority and  Absence of a comprehensive essential surgical and
administrative body to anesthesia equipment and supplies list
manage equipment,  Inadequate long-term prevention maintenance plan
consumables, and supplies

12
 Presence of a national drug  Poorly organized stock management system
and equipment list  Poor capacity of forecasting, quantification procurement,
and stock management of supplies and commodities
 Weak maintenance capacity (medical equipment)
 Low utilization of technology and innovations
 Poor equipment maintenance and reengineering
 Inadequate budget allocation
INFRASTRUCTURE
Strengths Weaknesses
 Increased investment in the  Inadequate health infrastructure
surgical and anesthesia  Poor private engagement
infrastructure (health centers  No medical science-oriented engineers assigned in
with an OR facility, general developing medical-friendly constructions
and primary hospitals)  All responsible sectors are not coordinated in construction
 Road, water, and electricity of health facilities
access is relatively  Health professionals are not consulted on designs, and
improved designs do not account for the status of people living in a
 Relative improvement in specific area, climate, or people with special needs
diagnostic and imaging  Absence of continuous preventive and curative
modalities infrastructure maintenance

HEALTH INFORMATION SYSTEM

Strengths Weaknesses
 Poor data collection, capturing, and reporting mechanism
 Low data quality
 Health information performance index is not assessed
 Inadequate anesthesia and surgery KPI incorporation in
national DHIS II
 Existing baseline facility
 No technology-oriented information gathering and
assessment
analyzing system
 Presence of national surveys
 Weak joint planning and monitoring of surgical and
 Presence of DHIS II
anesthesia service performances
 Surgery and anesthesia-
 Inadequate capacity-building of regional public health
related evidence generation
research centers
 Poor knowledge management system
 Poor health information technology (HIT) infrastructure
 Not included in woreda-based planning

HEALTH FINANCING
Strength Weakness
 Growing drug fund  Inefficient and complicated procurement process
revolving capital  Inadequate health insurance implementation
 Health care financing  Allocation of budget below WHO standard national health
identified as a priority on expenditure

13
 the Ethiopia HSTP II 
 No sustainability and self-reliant plan
 Donor-dependent reform and policy index
 Poor resource mapping, mobilization, and use
COMMUNITY
Strength Weakness
 Improving health-
 Poor community awareness of surgical and anesthesia
seeking behavior
care
 Initiation of community
 Low community enrollment in community health
health insurance
insurance
 Increased community
 Low community mobilization and engagement
demand for surgical
 Poor regulation of service delivery to the community
facilities
(community health insurance agency and hospitals)
Opportunities Threats
 Global focus area and  Political instability
initiative  Low trade agreement involving anesthesia and surgery
 Establishment of quality  Donor fatigue
control of laboratory service  Occurrence of Global pandemics (e.g., COVID-19)and
 Expanded medical schools disasters
and residency program  Migration of highly skilled medical professionals
 Disparity among graduating  High investment requirement for equipment and supplies
health professionals  Inadequate foreign currency
 Improving domestic  Interruption of internet services
production and import  Rapidly population growth
replacement (surgical  Harmful traditional practices acting as barriers to seeking
masks, gloves, and health services for the community
stretchers)
 Presence of biomedical
engineering training in
higher education institutions
 Diaspora willingness to
participate in health care
 Improvements in
information and
communication technology
infrastructure nationally
 Advancement of research
activities in universities and
institutes
 Growth in number of HIT
professionals
 Awareness of the gap
between national budget
expenditure

14
 Growing urbanization

15
3.2 Stakeholder Analysis
Stakeholders are identified and grouped according to their level of participation, interest, and
influence in the national surgical care program; and strategies are developed to involve and
communicate with each stakeholder group throughout the implementation of the SaLTS II
strategic plan. Key stakeholders considered to have a critical role in the implementation of the
strategic plan are ministry offices, teaching institutions, professionals and professional societies,
development partners, private health care institutions, governments, the community, and the
media. Greater community and civic society (professional and patient associations) engagement
will have a high impact on the achievement of the surgical care strategy. Alignment among
public institutions and partnering with private health facilities will also have a critical impact on
the implementation of this strategic plan.
Tabe 5 Stakholder Analysis

Stake Behaviors we Stakeholde Resistan Instituti Engagem Strate

holde desire rs’ interest ce issues onal ent gic
rs respons strategy impac
e t
Commun Health lifestyle, Timely surgical Attitude Advocacy, Community High
ity participation, and and anesthesia toward enhancemen forum, interest
engagement, ownership, care, health surgical and t of quality
health-seeking behavior education, anesthesia of surgical
community , low
access to health care, low and campaigns, power
information, satisfaction, anesthesia strengtheni
specialized inappropriat care, ng patient
surgical and e use of community association
anesthesia care, alternative mobilization
affordable care, medicine for surgical
s
compassionate and
surgical and anesthesia
anesthesia care care
Ministry Development of an Complete Lack of Advocacy, Meeting, High
offices industrial park for health, information prioritizatio proactive continuous interest
policy support for in-country about surgical n, limited collaboratio
production as well as tax and anesthesia trained n,
formal and and
policy revision for surgical care; technical human innovative informal high
and anesthesia supplies, support; power to leadership communica power
clear and transparent evidence guide and tions,
customs clearance, budget presentation surgical and managemen planning,
allocation, policy, ensure about the benefit anesthesia t system,
quality of higher education of in-country supplies and health
M&E
programs in surgery and manufacturing lack of service-
anesthesia, increase training of surgical and directives, oriented
sites, encourage research anesthesia resource policy and
and evidence-based practice supplies; proper limitation, directive
budget planning, long
reporting, and customs

16
Stake Behaviors we Stakeholde Resistan Instituti Engagem Strate
holde desire rs’ interest ce issues onal ent gic
rs respons strategy impac
e t
auditing; clearance
standardization process
documentation
Universit Production of a competent, Clear policy Limited Financial Curriculum High
ies ethical, and compassionate direction, clear resources and review interest
(surgical surgical workforce as well demand, leadership
workforc as an adequate number of financial and support of forums, , high
e training surgical staff; active leadership institutions collaborativ power
institutio engagement in research support for e meetings
ns) related to surgical systems; international
contributing to the collaboratio
development of guidelines n
and protocols for surgical
and anesthesia care
Professio Compassionate care, Continuous Poor Timely Consultatio High
nals competent and quality professional satisfaction, delivery of ns, interest
surgical and anesthesia care, development/ poor CPDs and
innovative and problem- medical understandi CMEs,
CPD/CME, , low
solving, system education ng of responsiven short/long power
management, ownership of (CPD/CME), national ess to course
the strategic plan career context, surgical trainings,
development, status quo, workforce onsite/offsit
motivation, burnout inquiries
recognition and
e courses,
retention planning
package, legal forums
protection,
liability
insurance,
conducive
working
environment
Develop Support of CPD and CME Evidence-based Narrow Clear policy Strategy Interme
ment development, assistance in problem sphere of and developme diate
partners advocacy of surgical and identification, interest, guidance,
(NGOs) anesthesia care, technical active limited regular
nt, M&E, interest
and resource support for participation of funder, activity and CPD/CME , high
implementation of surgical the surgical task accountabili audit developme power
and anesthesia care strategy force and related ty reporting, nt
stakeholders to advocacy
their program,
appreciation and
due value for
their
contribution by
regulatory
bodies and
concerned stake
holders, regular
reports

17
Stake Behaviors we Stakeholde Resistan Instituti Engagem Strate
holde desire rs’ interest ce issues onal ent gic
rs respons strategy impac
e t
Private Quality and affordable Participatory Poor Advocacy, Partnering, High
health surgical and anesthesia care, policies; resource engagement PPPs interest
care engagement in public- collaborative allocation in policy
institutio private partnerships (PPPs), stakeholders; for and strategy , low
ns enhance medical tourism disciplined, equipment developmen power
skilled, and and human t, strong
dedicated resources, regulation
surgical wororce delay in
adopting
new
policies,
limited
involvement
in teaching-
learning
process
Governm Ratification of Implementation Limited Establish Performanc High
ents proclamations, policies and of skilled strong and e appraisal, interest
(federal, directives, design and proclamations, workforce, sustainable
regional, implement surgical policies and limited capacity-
experience , high
zonal, workforce motivation and directives, safe resources, building and sharing, power
and retention package, allocate and quality national M&E policy and
woreda) adequate resource for surgical and political system, strategy
surgical and anesthesia care, anesthesia care context conduct familiarizat
organizational restructuring provision, regular
for surgical systems planning and review
ion and
strengthening reporting meeting for communica
stakeholder tion
engagement,
design and
implement
innovative
financing
scheme for
surgical and
anesthesia
care
Civil Proactive engagement, Clear policy Dissatisfacti Policy, Annual High
society ownership, participation guidance; on, poor financial, review interest
(professi involvement in collaboratio and
onal planning, n and leadership
meetings, , low
societies, implementation, communicat support; CPD/CME power
patient and M&E ion, capacity-
associati process passivity, building
ons) limited
resources

18
Stake Behaviors we Stakeholde Resistan Instituti Engagem Strate
holde desire rs’ interest ce issues onal ent gic
rs respons strategy impac
e t
Agencies Ensure sustainable Technical Administrati Act in Continuous High
(blood availability of support, active ve issues alignment engagemen interest
bank, pharmaceuticals, equitable engagement with the
Ethiopia and demand-based regulatory t, , high
n Food, distribution of policy, discussions power
and Drug pharmaceuticals and collaboratio
Authorit devices; ensure quality and n with the
y, safety of imported surgical MoH
Ethiopia and anesthesia devises;
n facilitate donations in a less
Pharmac bureaucratic way; shorten
eutical medical product registration
Supply process; ensure
Agency, performance-based licensing
health (institutions, professionals);
insurance develop a standard that can
, measure the service;
Ethiopia accreditation of health
n Public facility
Health
Institute)
Media Advocacy on surgical and Timely Medical Advocacy, Partnering Low
anesthesia care, , reporting, health journalism inter- interest
consultation and review of professional is not sectoral
reports before broadcasting engagement for available, response
, high
to the community, reports incorrect power
conducive environment and reports,
reporting for community ethical or
trust related to surgical legal
interventions disputes

19
 Goal, Strategic Objective, Interventions and
Targets

4.1 Vision Mission and Guiding Principles

4.1.1 Vision:
To see a healthy, productive, and prosperous society

4.1.2 Mission:
To promote the health and wellbeing of Ethiopians through improving access to quality
surgical and anesthesia care

4.1.3 Guiding Principles

 Equity
 Partnership
 Innovation
 People-centered
 Professionalism
 Accountability and transparency

4.2 The goal, Strategic Objectives, and Interventions

4.2.1 Goal
Reduce surgical related morbidity and mortality

4.2.2 Strategic Objectives and Intervention:

4.2.2.1 Strategic Objective 1: Equitable Access to Safe Surgical and Anaesthesia

Care in Ethiopia:
Discerption

Access to EESC has been identified as a critical gap in the development of health systems in
LMICs. Recently, the need to develop emergency and essential surgical services have increased
as surgically treatable disease are becoming a great public health burden, particularly in LMICs
such as Ethiopia. Addressing equitable access requires selected and focused intervention to
strengthen infrastructure in a way that enables health facilities to provide advanced surgical care
close to the community, and by availing competent, motivated surgical workforce to all corners
of the country. Ensuring the uninterrupted supply of medical equipment, essential medications

20
and other surgical care supplies shall also be the focus area of the fulfillment of equitable access
objective.

Strategic intervention

 Establish an effective leadership and management structure dedicated to overseeing

Surgical Care at the MoH and across all levels of the health system
 Assess and monitor that health facilities are equipped according to the national standard
list of drugs, equipment, and consumables for surgical care at all levels
 Support Production and Equitable Deployment of Competent Surgical and anesthesia
Workforce to Achieve Universal Health Coverage Standards
 Strengthen Recruitment, Motivation, and Retention Systems for the Surgical Workforce
 Expand essential surgical and anesthesia care and facilities providing this care
 Facilitate basic amenities (water, electricity) in all level of the health facility

4.2.2.2 Strategic Objective 2: Improve Efficiency of Surgical Systems in Ethiopia:

Discerption

System efficiency aims to increase productivity with fewer resources, a key intervention in low-
income countries such as Ethiopia. In the surgical systems process map, inpatient departments
and operating theaters are where most surgical care activities are carried out. Similarly in the
surgical system, the most active area of the processes is the inefficient weak link of the system.
Hence, looking for interventions addressing the efficiency gaps to utilize the available scarce
resource should be the focus of the surgical care strategy. Designing an efficient system requires
having a learning process that advocates the concept of a continuous quality improvement
culture. Building a resilient governance system across all the levels of the health systems with
the capacity for mobilization and engagement of all stakeholders shall also be the focus area to
have a more efficient surgical system. To guide all the decision-making in the health system to
reduce the inefficiency by reducing waste and develop an innovative health care financing
backed by a strong information management system shall be the core process area that the
strategies in surgery should address.

Strategic Intervention

 Strengthen the Medical Equipment Management Information System (MEMIS) for

surgical care
 Re-design the surgical care provision workflow
 Increase the productivity of the surgical workforce
 Standardized common supplies for procedures
 Strengthen periodic preventive and curative medical device maintenances

21
  The design motivation and recognition mechanisms for an efficient surgical workforce

4.2.2.3 Strategic Objective 3. Improve Effectiveness of surgical system in Ethiopia:

Discerption

This objective refers to the improvement of evidence-based practice that is consistent with
current professional knowledge. It mainly stresses the availing, and periodically updating as well
as improving compliance to the clinical guidelines, protocols and standard operating procedures.

Strategic interventions

 Build Capacity of the Surgical work Force

 Standardize major essential Outpatient Surgical and anaesthesia Services
 Update and avail clinical guidelines of surgical care guidelines, SOP, protocol
 Monitor and improve compliance to surgical care guidelines, SOP, protocol
 Institutionalize perioperative mortality audit system
 Improve surgical data management (data collection, utilization, data quality, and
improvements)

4.2.2.4 Strategic Objective 4: Improve People-Centered Surgical Care in

Ethiopia:
Discerption

This objective is about an approach to surgical care that consciously adopts individuals’, carers’,
families’ and communities’ perspectives as participants in, and beneficiaries of trusted surgical
systems that are organized around the comprehensive needs of people rather than individual
diseases, and respects social preferences. People-centered care also requires that patients have
the education and support they need to make decisions and participate in their care and that
carers can attain maximal function within a supportive working environment. People-centered
care is broader than patient and person-centered care, encompassing not only clinical encounters
but also including attention to the health of people in their communities and their crucial role in
shaping health policy and health services. Empowering and engaging individuals and families,
Empowering and engaging communities, Empowering and engaging informal carers and
professional associations are key means to meet this objective 7.

Strategic intervention

7
Framework on integrated, people-centred health services, WHO, 2016

22
  Strengthen Leadership and Management Capabilities and Partnership Skills Critical for
Mobilizing Technical and Financial Resources Needed to Strengthen Surgical Care at All
Levels of the Health System.
 Improve Awareness and Meaningful Engagement of Key Local and Global Stakeholders
to Strengthen Implementation of Surgical Care Strategy
 Strengthen Liaison and Referral Services
 Strengthen Community-Level and Pre-hospital Surgical Emergency, Trauma, and
Ambulance Services
 Conduct motivation and retention studies, advocate and support the implementation of
innovative career development and motivation and retention packages for the surgical
workforce
 Conduct surgical workforce professional development activities (continuous professional
development [CPD]), in-service training and coaching, etc.).
 Strengthen clinical and system mentorship, preceptorship, and coaching programs among
facilities (e.g., using a cluster base or a hub-and-spoke model).
 Support infrastructure development for teaching and learning materials including skill
development labs and learning technologies for online training and consultation.
 Support establishment of a model center for the development of surgical care (focusing
on surgical clinical skill development, surgical system management, safety, and quality
management, research work, and grant management).

4.2.2.5 Strategic Objective 5: Reduce Harm arise from surgical care provision in
Ethiopia:
Discerption

When expanding access for EESC, maintaining the quality of care is crucial. The safety of
surgical and anesthesia care can be significantly enhanced through the application of several
evidence-based interventions. Safety-wise, standard protocols, and safety tools neither supplied
nor adhered to existing safety protocols. Accordingly improving the patient identificatuion,
surgical site infections, falls, and other adverse events is a key.

Strategic intervention

 Ensure Availability of Uninterrupted Utility and Ancillary Services (Such as Water,

Oxygen, Power Supply, Laundry, CSD, and Communication System)
 Develop and introduce occupational safety measures for the surgical workforce (hepatitis
vaccine, liability insurance, legal support, medical insurance, adequate personal
protective equipment, etc.).
 Strengthen surgical safety practices (patient identification, surgical site marking SSI, fall,
anesthesia, adverse event, fire, surgical team communication )

23
4.3 Targets:

1. Reduce Delay for elective surgical admission from---- to ----

2. 2500 procedures per 100 000 Population by end of 2025
3. Reduce Perioperative mortality rate to < 2%
4. 100 % tracking of surgical related death
5. Reduce surgical site infection rate to < 5%
6. Increase Surgical service provision patient satisfaction by 50%
7. 100% woredas with access to essential surgical care.
8. Reduce anesthesia adverse event-----

24
 5. Implementation Arrangement:

5.1. Governance Structure

5.1.1. Surgical and Anesthesia Service Directorate (SASD)

The SASD Directorate formed under the Ministry’s office will serve as a primary owner and
leader of the SaLTS strategic plan. This Directorate serves as a national coordination body that,
in collaboration with regional state health bureaus, guides as to how emergency and essential
surgical care services should be standardized and operationalized across the country.
Additionally, it endorses national surgical care plans and mobilizes the necessary budget to
operationalize the program. The Ministry will support the establishment or adaptation of a
similar structure at subnational levels including regional health bureaus and zonal/woreda health
offices (see Figure 2).
As shown in the figure the Directorate will form (1) a program management team, (2) a technical
working group, and (3) monitoring, evaluation, and learning (MEL) departments or case teams.
The details of the scope of work and accountability mechanisms will be shown in the description
of the respective work structures. The major activities of the department/case teams are described
below:
 SaLTs program management department/case team. Project management teams for
surgical and anesthesia services will be established under the SASD office at all levels of
the health system. These teams act as an engine in the implementation of the national
surgical care strategy. In addition, the management teams will develop plans according to
direction from the SASD office and the SaLTS strategic plan. It takes an active part in the
supportive supervision and M&E of activities and gives the necessary feedback to the
respective and responsible bodies. The details of the scope of work and accountability
mechanisms will be described in their respective description of the work structures.
 Technical working group. The SASD office will form a surgical care TWG at national
and regional/zonal levels whose members may be comprised of complementary MoH
directorates and professional societies and multidiscipline professionals (obstetrics and
gynecology, surgery, anesthesia, nursing, and midwifery, and M&E, among others). The
details of the scope of work and accountability mechanisms will be described in terms of
reference.
 Monitoring, evaluation, and learning department/case team. The MEL team will
assist the Directorate in tracking program activities, monitor progress of key surgical care
performance indicators, and coordinate supportive supervision and learning activities.
The team will prepare annual reports and document best surgical care practices.
1. Figure 2: Organizational structure for a national surgical and anesthesia care
program

25
 MoH Ethiopia (National)

Surgical and Anesthesia Service Directorate (SASD)/Office (quality directorate)

National technical working National surgical care program Monitoring, evaluation, and
group management team learning team

Regional SASD office

Regional technical working Regional SaLTS program Regional monitoring and

group management team evaluation Team

Facility chief executive officer/ medical director

Surgical and anesthesia service director/office

SaLTS multidisciplinary team or quality management

unit

5.1.2. Facility Level

Hospital management will establish and organize the facility's surgical and anesthesia services
office. A surgeon, gynecologist, or anesthetist/anesthesiologist on the facility staff will lead the
office. The office will in turn establish and lead the SaLTS multidisciplinary team. The operation
theater manager will serve as team secretary. Each health facility should design jobs based on
need and relevance to the national surgical and anesthesia care and EESC strategic plan.
The SaLTS multidisciplinary team will be represented by staff from the following departments
or care processes:
 Surgery department
 Ob-gyn department
 Operating room (OR) and inpatient surgical wards
 Anesthesia department
 Nursing and midwifery department
 Post-anesthesia care unit (PACU)
 Pharmacy and laboratory departments
 Quality and data management unit

26
  Support functions including the Central sterilizing department (CSD), Infection
prevention, and biomedical engineering departments
Table 4 summarizes team leadership roles and responsibilities.
Health facility structure Roles and responsibilities

Hospital/health center  Establish a facility surgical and anesthesia services

chief executive directorate/office
officer/clinical
 Assign SaLTS leader, OR manager, and necessary team members
director/senior
management team  Supervise overall SaLTS activities
(SMT)
 Conduct baseline and ongoing assessment
 Engage senior professionals in leadership
 Allocate and mobilize resources
 Evaluate implementation progress
 Assess and reward champion provider
 Ensure availability of necessary supplies
 Ensure the availability and utilization of the WHO safe surgery
essential checklist
Facility surgical and  Lead, mobilize, and motivate the facility SaLTS,
anesthesia service multidisciplinary team
directorate/office
 Develop SaLTS-specific action plan for the facility
 Ensure that the surgical team works together and feels valued
 Review and report collected data monthly
 Arrange and undergo a surgical audit of mortality and morbidity
 Participate in the SMT representing the surgical team
SaLTs multidisciplinary  Support implementation of the facility SaLTS plan
team
 Conduct an ongoing assessment to advise the SMT and provide
feedback to service units
 Provide training to the clinical and nonclinical surgical staff
 Plan and supervise the activity of the respective units
 Discuss with the team how to improve the quality of surgical
activities
 Organize hospital-wide advocacy and communications
 Engage in all surgical team meetings

27
  Document all activities and submit reports

Full-time OR manager  Act as a secretary of the SaLTS implementing team

 Oversee day-to-day OR activity
Conduct daily supervision of key function units and provide
information to the SaLTS coordinating team

5.1.3. Health Centers

To cascade the leadership structure at the health center level, an SASD office will be established
under the medical director and led by a surgical team leader/Anesthetist/integrated emergency
surgical officer [IESO]).

5.1.4. Federal Health Facilities

Hospitals under the federal government will directly communicate with the SASD office at the
MoH. However, the structure in federal health facilities is similar to hospitals elsewhere.

5.1.5. university Hospitals

University hospitals will establish a SASD office under the chief clinical director or medical
service vice provost.

28
 6. Monitoring and Evaluation:
Successful implementation of the surgical and anesthesia care strategy will rely on a robust M&E
system. Hence, M&E will be an integral part of the strategy. Continuous monitoring of progress
and evaluations of outcomes and impact will support evidence-based decision-making for
effective, efficient, and synergistic implementation of programs. Moreover, M&E will be
integrated into knowledge management efforts to help document lessons and sharing of
experiences both nationally and in the international arena.
The main purpose of the M&E framework is to provide data that are essential to track the
progress made in the implementation of surgical and anesthesia care activities; to facilitate
proper planning, coordination, and implementation of the surgical and anesthesia care activities;
and to ensure accountability of the various stakeholders.
The monitoring, evaluation, and learning (MEL; see Box A) plan provides a set of indicators to
be monitored regularly to show the impact of the surgical and anesthesia care activities.
Indicators should be selected that reflect both processes and outcomes.
Learning is a continuous process of analyzing and interpreting information and knowledge
(monitoring data, evaluation findings, innovations, stories, person‑to‑person exchanges, and new
operations research learning) that brings to light new promising practices or calls into question
received wisdom. Learning leads to the adaption of strategies and/or activities to sustain the most
effective and efficient path to achieving success, as well as the identification of strengths and
promising practices to be replicated within the project and beyond.
The purpose of M&E is to routinely generate quality data that provides specific information
support to the decision-making process at each level of the health system for improving the
performance of emergency surgical and anesthesia care.

Box A: Monitoring, Evaluation, and Learning

Monitoring is the systematic and continuous collection of information over time to
measure progress or change of an activity or objective, using predefined indicators of
progress and/or impact of an intervention.
Evaluation is the process by which one determines if the program achieved its overall
and specific objectives. It usually is an assessment at one point in time to determine
the impact of the project.
Learning can be defined as a continuous and intentional process of analyzing a wide
variety of information sources and knowledge.

29
Table 5: Key elements of the Hospital Performance Monitoring and Improvement Framework

Element Description

 A set of core hospital KPIs on SaLTS that meets the needs of governing
boards, CRCPs, the MSGD, and the public will streamline reporting
processes and prevent duplication of efforts by the different stakeholders.
The burden on hospitals will be minimized.
 A common set of KPIs on SaLTS will allow tracking of hospital
performance on surgery over time, and making comparisons between
hospitals and regions.
KPIs on
 Governing boards can use the KPIs on SaLTS to monitor hospital
SaLTS
performance. Problems will be identified at an early stage, allowing
governing boards to take remedial action where necessary.
 Hospitals should report their KPIs on SaLTS to the RHB CRCP every
month. Comparisons between hospitals can be made, identifying best
practices as well as areas needing improvement.
 The SaLTS team at the HSQD can review cluster, regional, and hospital
performance and identify areas needing additional support.
 Site-level indicators are used to monitor the performance of surgical
units at each hospital but are not reported to CRCPs and the MSGD.
Site-level Surgical teams and hospitals will use site-level indicators routinely to
indicators improve their performance. The clinical mentors assigned to each
cluster will also use the site-level indicators for routine performance
improvement.
 Supportive supervision site visits to hospitals should be conducted to
check (validate) hospital performance concerning the KPIs on
SaLTS, identify good practices, and provide supervision and
guidance to help hospital surgical units improve areas that require
strengthening.
Supportive
 Supervision should be conducted by a team consisting of, for
supervision
example, cluster mentors, RHB CRCP staff, MSGD staff, staff from
site visits
other hospitals (e.g., CEOs), and other key partners. All stakeholders
may delegate relevant experts during supervision visits.
 All supervision should be under the direction of the respective
CRCP. No stakeholder should conduct supervision without the
approval/awareness of the CRCP.

30
 Regional
 Review meetings between the CRCP and hospitals (either region-
wide or in clusters) will allow for benchmarking and dissemination of
good practices.
 At each review meeting, hospitals should present a performance
report based on their KPIs on SaLTS. Hospitals will have the
opportunity to share successes and challenges to learn from each
other.
 Regional “all hospital” review meetings can also be used to discuss
Review
other relevant topics.
meetings
National
 Review meetings between the MSGD and all regional CRCPs will
allow for benchmarking and the dissemination of good practices
between regions.
 At each review meeting, CRCPs should present a regional
performance report based on their KPIs. Regional CRCPs will have
the opportunity to share successes and challenges to learn from each
other.
 MSGD/HSQD/CRCP meetings can also serve as forums to discuss
other relevant topics.
Operations
 Surveys, studies, supervision, and reports will be used to assess the
research,
progress made in the implementation of the surgical and anesthesia
studies, and
care interventions, and their outcomes and impact.
evaluation

31
 6.1. Data Sources and Management
Different data sources will be used to monitor the progress of surgical and anesthesia care. For
instance, all public and private facilities collect facility-based data through the following systems
relevant to surgical and anesthesia care.
 Health management information system (HMIS) is the primary source of routine data
on health services including referral services, district hospitals, and health centers.
 Key performance indicators (KPIs) are the set of indicators with the primary function
of assisting hospital SMTs, governing boards, RHBs, and MOH to oversee hospital
operations.
 Human resource information system (HRIS) has active records of all health workers in
the country.
 Logistics management information system (e-LMIS) provides data on the supply and
use of medicines and commodities.
 Geographical Information System provides a means of analyzing coverage of general
or specific services in relation to needs and how these services are related to
communities, each other, and the larger health infrastructure.
 Operations research, studies, and evaluation will be used to assess progress made in
the implementation of the surgical and anesthesia care interventions, outcomes, and
impacts of interventions.
 National Health Accounts (NHA) provided a direct measurement of burdensome health
spending. It will be used to assess the household’s protection of surgical care-related
impoverishing and catastrophic expenditure.
 Service availability and readiness assessment (SARA) provides information on a set of
tracer indicators of service availability and readiness. It provides reliable information on
service delivery (such as the availability of key human and infrastructural resources), on
the availability of basic equipment, basic amenities, essential medicines and diagnostic
capacities, and on the readiness of health facilities to provide basic health-care
interventions relating basic and comprehensive emergency obstetric care.

32
Annex 3: Logic Model for the Monitoring Evaluation and Learning

MONITORING AND EVALUATION FRAMEWORK OF THE NATIONAL SURGICAL CARE STRATEGY

INPUTS PROCESSES OUTPUTS OUTCOME IMPACT

 competent and
motivated
surgical and
INDICA anesthesia
TOR workforce
DOMAI  improved
N Health facility
readiness
 Evidence based
care
 Effective
leadership and
management

Data Health facility assessment, routine HMIS, KPI’s, Health

source
Analysis
Data quality assessment; Triangulation of data from different sources, Comparison of performance
and
synthesi against targets; and national and Global commitments
s
Commu Regular reporting and feedback, Annual Health care quality summits, Learning collaborative sessions,
nication
and use
EHAQ, Review meeting including ARM,

33
Table: Key indicator reference for the SaLTS program

34
 Implementation plan
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
Strategic Objective 1: Access to surgical care
Establish SaLTs Established
leadership structures at leadership
0 Yes
MOH and across all levels structure
of health system (Y/N)
Familiarizing the new
Number of
structure/ surgical and
advocacy
anesthesia service 1 1
- - -
sessions
directorate/Office to
conducted
different stakeholder

Conduct regular meeting number of

(TWG and SaLTs meetings 20 4 4 4 4 4
Establish an effective Management team conducted
leadership and
management structure Approved
1.
dedicated to overseeing civil service
1
Surgical Care at the MoH allocated
Identify and recruit potential
and across all levels of the health work
members for the leadership Yes Yes Yes
health system force for
and management team
surgical
service
(Y/N)
Assist and empower
Established
professional societies to
surgical
contribute for governance in Yes Yes
- - -
consortium
surgery and anesthesia
(Yes/No)
service
percentage
Ensure proper data of facilities
management and report at with timely 92% 82% 92% 92% 92% 92%
all levels and
complete

35
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
DHIS-2
report

Update the national standard

list of equipment, drugs and Number of
consumables for surgical standard list 1 1
- -
care (Emergency, Essential updated
Assess and monitor that and advanced surgical care).
health facilities are
equipped according to the Conduct national equipment Number of
1.
national standard list of survey and promote National 1 1
- - -
2
drugs, equipment, and redistribution of resources Survey
consumables for surgical
care at all levels Support preservice and In-
Number of
service training program to
training
staff to improve their 6 6
sessions
procurement and supply
conducted
chain management skills
Undergo regular task
analysis and generate
evidences to promote and
advocate new cadre
professionals, which can Number of
improve access to surgical new surgical
Planned to be integrated with
Support Production and care and enhance surgical cadres/Disci 1 1
- - - SARA
Equitable Deployment of system efficiency (IESO, plines
1. Competent Surgical and OR managers, OR produced
3 anesthesia Workforce to technicians, emergency
Achieve Universal Health surgery physicians, carrier
Coverage Standards pathway and ladder for
surgical workforce etc.)
Conduct Workload Regional
indicators for staffing needs surgical
(WISN), forecast surgical work force Yes Yes
- - -
work force requirement and density per
monitor equitable regions
36
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
distribution among regions identified
(Yes/No)

Revise standards of surgical

care facilities and apply Developed
people centered principles standards Yes -
Yes
- -
for renovation or (Yes/No)
construction
Develop a guide for regular
preventive maintenance of Developed
surgical equipment and standard /
Yes -
Yes
- -
infrastructure management guide
system for perioperative (Yes/No)
care
Mobilize financial, material,
Resource
and technical resources
mobilization Yes Yes Yes
- - -
based on assessment
Expand essential surgical done
findings and priorities
1. and anesthesia care and
5 facilities providing this
care Renovate and build post- Number of
anesthesia care units across facilities 33 16 17
- -
the country with PACU

Renovate and build surgical, number of

obstetrics and anesthesia renovated
20 -
5 10 5
care suites and operation surgical
theaters suites
Establish specialty and
subspecialty surgical, specialty
obstetrics and anesthesia road map
Yes Yes Yes Yes Yes Yes
units capable of providing developed
advanced surgery across the (Yes/No)
country

37
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
Number of
health
Ensure availability of facilities
40 10 10 10 10
alternative water sources with
alternative
water source
percentage
of health
Ensure availability of facilities
uninterrupted electric power with 40 10 10 10 10
Facilitate basic amenities supply alternative
1. power
(water, electricity) in all
6 source
level of the health facility
number of
health
Ensure sustainable supply of
facilities 25 2 7 8 8
oxygen
with oxygen
plant
number of
Renovate and build new
CSR
sterilization units across the 25 5 7 7 6
renovated
country
and built

Strategic Objective 2: Improve efficiency

Conduct periodic inventory Number of
of equipment for surgical inventory 5 1 1 1 1 1
care conducted
Preventive
Strengthen the Medical and curative
Develop guide for
2. Equipment Management maintenance
preventive and curative Yes
1 Information System guideline -
maintenance
(MEMIS) for surgical care prepared
(Y/N)
Conduct periodic end user Number of
training on equipment for trainings 20 3 4 5 8
surgical care conducted

38
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
Number of
Asses the current surgical assessment
16 16
provision workflow vists - - -
2. Re-design the surgical conducted
2 care provision workflow Designed
Design standardized
suitable to
surgical care provision Yes Yes
- - -
workflow
workflow
(Y/N)
Implement strategies to
enhance productivity of
surgical team: plan number
of surgeries per surgeon and Number of
surgical team considering workshop 1 1
- - -
the case mix (design and conducted
implement new productivity
matrix tool in EMR
Established HOSP.)
2. Increase the productivity Number
introduce and implement the
3 of the surgical workforce training 7 1 2 2 2
new Matrix
conducted
Motivation
Design strategy to motivate
strategies
productive surgical Yes Yes
- - -
designed(Y/
workforce
N)
Introduce recognition
Number of
system for health work force
awarded 76 19 19 19 19
who use the resources
teams.
efficiently
standardizati
Develop minimum supply
on document
requirement for surgical Yes Yes
- - -
developed
procedures
(Y.N)
2. Standardized common
Number of
4 supplies for procedures
Monitor standardized procedures
supplies for each with 22
-
6 7 9
procedures standardized
supply list

39
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
Guideline on
surgical
Develop Surgical waiting waiting list
and OR scheduling & OR Yes Yes
- - -
guideline scheduling
Expand a patient developed
2.
scheduling management (Y/N)
5
system (SWOS) Number of
trainings
Scale up the SWOS
conducted
software to all Ethiopian 22
-
6 7 9
on SWOS
hospitals.
software
utilization
Day care
Introduce day care surgery surgery
1 1
guideline conducted - - -
(Y/N)
Number
hospitals
Identify health facilities and
asssed for
establish to start day care 33 17 16
- -
day care
surgery
surgery
readiness
Number
health
2.
Improve surgical volume facilities
6
Decrease surgical backlog received
20 10 10
in 10 high burden Hospitals support for - -
surgical
backlog
reduction
Decrease surgical backlog
caused by lack of supplies
for surgical problems Backlog
####
related to ENT, Plastic reduction #####
20% 20% 20% 20%
Ophthalmology, rate
Orthopedics and trauma.
Pediatric Neurosurgery,
40
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
Pelvic Organ prolapse

Strategic Objective 3: Improve effectiveness

Conduct trainings for
Number of
surgical workforce on
SWF trained
surgical care competencies National level training for
3. Build Capacity of the on surgical
1 Surgical work Force
(OR leadership, Surgical
care
1,830 330 400 450 650 highload Hospitals (10 Per
system management, Hospital)
competencie
clinical skills, scheduling
s
etc.)
Number of Trainimng material dev't &
Conduct surgical workforce
In-service national level training for
professional development
training
30 -
15 15 highload Hospitals (5 Per
activities Hospital)
conducted
Strengthen clinical and Number of
Mentoring Guide dev't &
system mentorship, mentorship
preceptor ship and coaching support
1,464 264 320 360 520 Mentoring visit to PH by lead
Hospital
programs among facilities provided
number of
health
Support infrastructure facilities
development for teaching supported
and learning materials with skill Supporting 10 Hospitals
through equping skilllabs &
including skill development labs, 10 5 5
- online training materinal (15
labs and learning learning milion birr per Hospitals)
technologies for online technologies
training and consultation for online
training
consultations
Support establishment of a
model center for the
development of surgical Number of
care (focusing on surgical trained staff
clinical skill development, on surgical
630 160 170 150 150
surgical system care
management, safety and
quality management,

41
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
research work and grant
management)

Number of
Health
facilities
Update and avail clinical Avail and aware surgical
3. implementin SOP advocacy for 33
2
guidelines, SOP, protocol standard operative
g standard
53 20 33
- - Hospitals (12 Per Hospital)
of surgical care procedures (SOP)
operative
procedures(S
OP)
Training
package for
Develop training package mortality
for mortality review review
0 Yes
- - -
developed(Y
/N)
Institutionalize
3. Number of
perioperative mortality
3 health
audit system Provide Capacity building
facilities
to health facility
with TOT
representatives on 5 5
- -
trained
perioperative mortality
health
review (TOT)
professionals
on POMR.
Number of
Provide Capacity building health
to health facility facilities
representatives on with trained 330 33 150 147
perioperative mortality health
review (Basic) professionals
on POMR.
Improve surgical data New surgical
3. management (data Introduce the new surgical measures
4 collection, utilization, data measurements introduced
Yes Yes
- - -
quality, and (Y/N)

42
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
improvements) Number
trainings
Design capacity building sessions
modality for surgical related conducted 20 6
-
14
-
data management on surgical
data
management
Number of
Hospitals
Provide all surgical related
provixed
SOP, protocol and
with SCG,
330 330
-
guidelines
Monitor and improve SOP and
3. compliance to surgical Protocols
5 care guidelines, SOP, Monitor adherence of health Number of
protocol facilities to surgical related survey visits 33 -
17 16
-
guidelines conducted
Numbef of
Evaluate the compliance to
surgical policies
evaluation 1 -
1
- -
report
Standardize major ( high standardizati
3. priority ) essential Conduct standard on document
6 Surgical and anesthesia development workshops developed
Yes Yes
-
care (Y.N)
Strategic Objective 4: Improve people centered surgical care
Provide and allocate budget
financial support at all allocated Yes Yes Yes Yes Yes
Strengthen Leadership and levels health system (Y/N)
Management Capabilities
Guidline for
and Partnership Skills
Develop guideline for stakeholder
Critical for Mobilizing
4.
Technical and Financial
engagement policy of engagement Yes -
Yes
- -
1 stakeholders develop(Y/N
Resources Needed to
)
Strengthen Surgical Care
at All Levels of the Health Training
Design leadership
System. package
support/training package
developed
Yes Yes
- - -
based on identifying gaps
(Y/N)

43
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
Number of
Implement leadership
support/training package
trainings 36 9 9 9 9
conducted
Identify major leadership number of
gaps using OCA at all levels site
of surgery and anesthesia assessment
32 16
-
16
-
service conducted
Number of
Conduct SaLTs mid-term
and end-term evaluations
evaluations 2 -
1
-
1
conducted
Number of
Conduct regular supervision regular
on SaLTs program supervision
64 16 16 16 16
conducted
Conduct awareness creation
workshops for targeted
stakeholders (professional
societies, community and number of
patient associations, media, workshops 1 1
- - -
government offices, etc.) conducted
using face to face and
virtual platforms including
social medias
Improve Awareness and
Develop policy briefs,
Meaningful Engagement policy brief
public communication and
of Key Local and Global
branding tools (Letter,
produced Yes Yes
- - -
Stakeholders to (Y/N)
rollup banners)
Strengthen
promotions
Implementation of
of surgical
Surgical Care Strategy Use surgical champions and
care
ambassadors to promote
champions
Yes Yes Yes Yes Yes
surgical care
recognized(
Y/N)
Identify relevant
number of
professional network and
promotions
scientific conferences to
on SaLTs
4 1 1 1 1
promote surgical care
strategy
strategy and mobilize
44
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
resources from donor
communities

Promote PPP model to

PPP
ensure equitable and
initiated 0 Yes Yes Yes Yes
affordable surgical care
(Y/N)
(Flagship Initiative)
Health
sector
Develop and implement
Strengthen Liaison and referral
Referral Services
comprehensive surgical Yes Yes
- - -
policy
referral linkage.
prepared
(Y/N)
Trauma
severity
score
utilization
in
Collaborate with ECCD to
Emergency
implement trauma severity
scoring and management
and 0 Yes
- - -
Ambulances
system
service
Strengthen Community- system
Level and Pre-hospital designed and
Surgical Emergency, implemented
Trauma, and Ambulance (Y/N)
Services
Number of
capacity
Provide capacity building
building
training for Emergence and
training
8 -
4
-
4
ambulance service staffs
sessions
conducted
Conduct National Assessment
community surgical need conducted(Y Yes Yes
- - -
assessment /N)
Strategic Objective 5:Reduce harm

45
S
N Intervention Major activity Indicator Target Year 1 Year 2 Year 3 Year 4 Year 5 Assumption
.
Develop national
occupational safety Occupationa
guideline ((hepatitis l Safety
vaccine, liability insurance, framework/g
legal support, medical uideline
Yes Yes
- -
Yes
Develop and introduce
insurance, adequate developed
occupational safety
personal protective (Y/N)
measures for the surgical
equipment, etc.)
workforce
COCID 19
Provide immunization for
immunizatio
COVID-19 and Hepatitis
vaccination for surgical
n Support Yes Yes Yes
- -
provided(Y/
5. workforce
N)
1
Improve capacity of surgical SSC
workforce on safe surgical Utilization 32 6
-
13 13
practice rate
Strengthen surgical safety
Surgical
practices (patient
safety
identification, surgical site Support health facilities to
practice
marking SSI, fall, implement surgical safety Yes Yes
- - -
Guildline
anesthesia ,adverse event, practice guideline
developed
fire, surgical team
(Y/N)
communication )
Number of
Surgical workforce fire
trained staff 73 -
36 17 20
safety training
on fire safety

46
Table: 1: Budget summary

S.n. Strategic objectives Year 1 Year 2 Year 3 Year 4 Year 5 Total

Strategic Objective 1: Access to surgical

1 1,801,124 106,907,790 283,750,750 142,759,907 164,275,907 699,495,478
care
2 Strategic Objective 2: Improve efficiency 6,538,846 154,030,642 102,790,882 147,265,858 110,791,266 521,417,494

Strategic Objective 3: Improve

3 4,845,568 99,864,815 443,026,401 444,193,453 36,511,121 1,028,441,358
effectiveness
Strategic Objective 4: Improve people
4 13,800,000 70,168,012 8,878,801 5,339,601 8,878,801 107,065,215
centered surgical care
5 Strategic Objective 5:Reduce harm 3,573,058 7,285,858 4,855,200 7,948,416 20,089,474 43,752,006
Grand total 30,558,596 438,257,117 843,302,034 747,507,235 340,546,569 2,400,171,551

47
 7. Annexes
Annex 1: Indicator matrix

S Types of Mid-term Final

. Indicato level of data data Frequen Baselin Target(202 target(202
N Indicator rs collection source cy e 3) 5)
Surgical
Service
outcom
provision
e
patient Quarterl
1 satisfaction Health Facility DHIS-2 y 44% 49% 54%
Surgical
Outcom
volume/100,0
e
2 00 population Health Facility DHIS-2 monthly 1250 2500
Perioperative outcom
3 mortality rate e Health Facility DHIS-2 monthly < 4% <2%
Proportion of
surgical HPMI-
Process
related death Hospit
4 tracked Health Facility al KPI monthly 50% 100%
Proportion of
surgical HPMI-
Process
related death Hospit
5 tracked Health Facility al KPI monthly 50% 100%
Safe surgery HPMI-
checklist Process Hospit
6 Utilization Health Facility al KPI monthly 50% 100%
Percentage of
population
with access to
Process
essential
surgical care Every 2 within
7 within 2 hr. Health Facility SARA Years < 4hrs 2hrs
Surgical work
force/ Input Every 5
8 100,000 Population EDHS Years 1 5 10

48