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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.