Lessons Learned from Development and Implementation of the National Surgical, Obstetric and Anaesthesia Plan in Ethiopia: a qualitative study

BackgroundThe Saving Lives Through Safe Surgery (SaLTS) project was launched in 2016 by the Ethiopian Ministry of Health to improve access and quality of surgical and anaesthesia care throughout Ethiopia. A key action of SaLTS was to develop a National Surgical, Obstetric and Anaesthesia Plan (NSOAP). The aim of this study was to explore barriers and facilitators in the development and implementation of this plan in Ethiopia. MethodsWe conducted semi-structured interviews with 12 key stakeholders involved in developing and implementing the NSOAP at national and regional level in Ethiopia. Thematic analysis was performed. ResultsThe attention given to safe surgery after the Lancet Commission on Global Surgery that reported in 2015, provided key impetus to commitment from the Ethiopian government to develop an NSOAP. Another important opportunity while drafting the plan was the engagement of relevant and motivated professionals. However, major challenges during development included a lack of consistent leadership, no prior experience to benchmark from, the extended time taken to complete the plan, the lack of exclusively dedicated staff, varying engagement, awareness and commitment of regional bureaus and poor quality of available data to inform the situation analysis. Key facilitators of implementation were ownership of the plan by the government and involvement of a multidisciplinary implementation team. However, this was undermined by poor cost estimation and inadequate commitment of financial resources, the low quality of surgical equipment and supplies, and the lack of dedicated human resources, data management systems, ongoing stakeholder engagement, and government accountability. Recommendations to increase the success of future planning and implementation included the need to properly estimate resources and financial impact, carry out a careful baseline assessment, implement checklists for monitoring and evaluation, ensure reasonable resource allocation and involve grassroots regional stakeholders from the beginning. Alongside this, countries need to have committed leadership and transparency in setting goals to bring about broad stakeholder engagement. ConclusionEthiopia showed early commitment to strengthen surgical systems and improve surgical care. Lessons learned can help to guide and encourage other countries to develop realistic NSOAPs and support their effective implementation on the ground.