Can you provide an overview of the Saving Little Lives program?

The Saving Little Lives (SLL) project in Ethiopia aimed to reduce newborn mortality from 33 to 12 deaths per 1,000 live births by 2025. To achieve this, the program focused on training and mentoring healthcare providers, equipping them to deliver quality care during birth, in neonatal intensive care units (NICUs), and in Kangaroo Mother Care (KMC) units. Initially targeting regions with the highest newborn deaths, the program expanded to 290 hospitals by 2023. Originally planned for 2021–2023, the timeline was extended to 2024 due to conflicts in Tigray, Oromia, Amhara, and SNNP regions.

The Saving Little Lives program was launched before the escalation of the conflict in the Tigray region. How did the increased conflict in Tigray affect program implementation?

While we were preparing for SLL implementation in Tigray, the war broke out. As a result, vital services like maternal and child health and emergency care were disrupted. In addition, there was a surge in health needs due to malnutrition, disease, and violence, pushing the already fragile system to near-total breakdown. Tigray's healthcare infrastructure essentially collapsed.  
When it came to newborn care services, the war significantly hampered newborn care projects due to widespread destruction of health facilities, including NICUs and delivery rooms. The displacement and targeting of healthcare workers led to a critical shortage of skilled personnel. Planned interventions like the Saving Little Lives (SLL) project faced major obstacles in implementation, hindering our efforts to reduce neonatal mortality and improve newborn health outcomes in the region.

How did you address these additional challenges?

The SLL project faced major challenges during the war, including a financial system collapse that froze Mekelle University's accounts. In response, UNICEF Ethiopia, the SLL consortium, and the project's principal investigator devised an innovative solution. The project was temporarily managed through UNICEF's Tigray field office, enabling fund transfers and the resumption of critical newborn care activities.  

During this challenging period, SLL became a vital lifeline, standing as the only active initiative focused on newborn care in the region. Healthcare providers in Tigray still recall the SLL project was the sole opportunity for professional development and capacity building in areas like labor and delivery, Neonatal Intensive Care Units (NICU), and Kangaroo Mother Care (KMC).

What measures did you and your team take to mitigate the impact of the conflict on the program?

In the face of the conflict, our team at the MARCH Research Center in Mekelle University made the decision to keep the Saving Little Lives (SLL) project alive no matter what. Our dedicated research team undertook extraordinary efforts, often walking long distances to reach health facilities, providing crucial mentorship and on-site training. This dedication put them in direct danger, with team members experiencing active warfare firsthand during mentorship visits in highly volatile areas.  

What most impressed you about the adaptability of the program?

Looking back at the Saving Little Lives project in Tigray and considering the absolute devastation caused by the conflict, it's truly remarkable what we achieved. As the evaluation coordinator, I can tell you, it wasn't just impactful; it was a lifeline. 

Think about it – amidst the severe disruptions, SLL stood as the only newborn care initiative still functioning in the region. It became this incredible beacon of hope, reaching newborns who were in desperate need. Healthcare providers on the ground still talk about it as being the single source for any kind of capacity building in essential areas like labor and delivery, the NICU, and KMC during that crisis.  

What also impressed me was the project's ability to adapt and even continue to monitor outcomes despite the ongoing conflict. That commitment to accountability and learning in such challenging circumstances was truly exceptional. While the war hindered the full potential impact, SLL provided this absolutely vital foundation, a springboard to rebuild newborn care services once some semblance of stability returned.  

What was the impact of the Saving Little Lives program in Tigray?

When you look at the specifics in Tigray, our strategic focus paid off. We successfully engaged with 30 out of the 40 targeted health facilities. That meant we could deliver our mentorship program on the core minimum care packages for newborns, as well as in the NICUs and KMC units, in those facilities. That was a monumental achievement.

The way we approached capacity building for the healthcare providers was also incredibly effective. Training over 60 health workers as Trainers of Trainers on the essential interventions for births, NICUs, and KMC, and then seeing them go on to train another 383 colleagues within their units? That cascading effect created a ripple of positive change. It was, without a doubt, a huge leap forward in strengthening the healthcare workforce. 

And let's not forget, SLL was the only active project after the Tigray war and the subsequent siege. During that dark period, when healthcare providers weren't even receiving their salaries due to the blockade, the SLL project was a source of hope, empowering healthcare workers.

So, while the overarching goals of Saving Little Lives were ambitious, its impact in Tigray, given the context, was nothing short of remarkable. We reached a significant number of health facilities, equipped them with essential tools, and empowered healthcare workers through targeted training and mentorship. It was, without a doubt, a cornerstone in the effort to revitalize the collapsed health system in Tigray, specifically in newborn care, and laid an absolutely critical foundation for newborns in the region. I am truly impressed by what we were able to accomplish against all odds.

How important is partnership and collaboration for successful program implementation?

From my perspective, I can't overstate how essential partnership and collaboration were to its success. It wasn't just important; it was the bedrock upon which the entire initiative was built, especially in the incredibly challenging context of Tigray.

What truly set the SLL project apart was the strength of the partnerships across universities and the Regional Health Bureaus. This collaboration was a game-changer. It allowed us to achieve far more than any of us could have accomplished alone. The donors and contributors to the SLL project should be incredibly pleased and highly commended for recognizing the value of this approach and for contributing their resources.

I want to particularly highlight the collaboration we had with Laerdal Global Health. Their support, with the Global Financing Facility (GFF), and their provision of essential neonatal equipment was deeply valued by the mentors and mentees. It made a tangible difference on the ground. Furthermore, the capacity-building project embedded within the SLL project was the foundation of the SLL project's success. It went beyond just equipment; it was an investment in the future. The fact that the project supported an embedded PhD capacity development program, with almost eight PhD students directly or indirectly benefiting, represents an investment in long-term capacity building within the region.  

Looking ahead: What are the next steps?

We can't afford to lose momentum, especially considering the fragility of the healthcare system post-conflict. 

First, a comprehensive assessment of those 30 health facilities we supported is essential. We need to understand what equipment is still functional, what needs replacing, and identify any new gaps that have emerged.  

Next, we need to reinforce the capacity building efforts. While we trained a significant number of healthcare workers, ongoing mentorship and supportive supervision are crucial to ensure the sustainability of the skills and knowledge transferred. We should explore options for refresher courses and potentially expand the training to reach more healthcare providers in those facilities and look at extending to the remaining facilities we initially aimed to reach.

We need to ensure a consistent supply chain for essential medications and consumables for newborn care is paramount. We need to work with relevant authorities and partners to strengthen the procurement and distribution systems.

Given the innovative approach we took to monitoring outcomes during the conflict, we need to further refine and strengthen these monitoring and evaluation mechanisms. This will allow us to track progress, identify challenges early on, and make data-driven decisions to optimize the program's impact as the health system recovers.

Finally, and maybe most importantly, we need to advocate for the integration of newborn care as a priority within the broader health system recovery plans for Tigray. The lessons learned and the successes achieved through the SLL project should inform policy and resource allocation decisions to ensure that newborn survival remains a key focus in the long term.

In sum, the next steps involve a multi-pronged approach: assessing needs, reinforcing capacity, ensuring supplies, strengthening monitoring, and advocating for policy integration. By taking these steps strategically and collaboratively, we can ensure that the positive impact of the Saving Little Lives project continues to grow and contributes to a lasting improvement in newborn survival in Tigray and throughout the rest of Ethiopia.