{"title":"From missions to systems: rethinking international surgical support in low- and middle-income countries.","authors":"George Wharton,David Jones,Robert Yates","doi":"10.1093/bjs/znaf212","DOIUrl":"https://doi.org/10.1093/bjs/znaf212","url":null,"abstract":"","PeriodicalId":136,"journal":{"name":"British Journal of Surgery","volume":"364 1","pages":"xv15-xv17"},"PeriodicalIF":9.6,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145710962","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Gerard McKnight,Hassan Ali Daoud,Rocco Friebel,Rachel Hargest
INTRODUCTIONPrioritizing resources is essential for low-income countries aiming to improve surgical systems effectively. Few validated tools exist to facilitate this. The authors aimed to address this through the novel application of an existing training needs analysis (TNA) tool to a surgical context in a low-income country.METHODSA questionnaire was designed as a mixed-methods, online survey to capture quantitative and qualitative data based on the Hennessy-Hicks training needs analysis (HHTNA) Questionnaire. The survey was distributed by collaborating organizations in Somaliland.RESULTSResponses were received from 41 anaesthesia providers (APs) and 69 surgical providers (SPs), giving a response rate of approximately 59% of APs, 33% of surgeons, and 21% of obstetricians in Somaliland. The HHTNA of APs highlighted that emergency front of neck access (cricothyroidotomy) was a 'high intervention priority' procedure among APs. Regional anaesthesia, medical management of co-morbidities, and anaesthesia in geriatric populations were also considered performance outliers and should also be the focus of further intervention. Importantly, mixed interventions were desired, indicating that training alone would be insufficient, and that improvements to the work situation also need to be addressed.CONCLUSIONThis study has demonstrated that conducting a pragmatic TNA of the surgical team in a low-resource setting, such as Somaliland, is both feasible and can generate useful data to guide training and professional development.
{"title":"Training needs analysis of surgical teams in Somaliland.","authors":"Gerard McKnight,Hassan Ali Daoud,Rocco Friebel,Rachel Hargest","doi":"10.1093/bjs/znaf216","DOIUrl":"https://doi.org/10.1093/bjs/znaf216","url":null,"abstract":"INTRODUCTIONPrioritizing resources is essential for low-income countries aiming to improve surgical systems effectively. Few validated tools exist to facilitate this. The authors aimed to address this through the novel application of an existing training needs analysis (TNA) tool to a surgical context in a low-income country.METHODSA questionnaire was designed as a mixed-methods, online survey to capture quantitative and qualitative data based on the Hennessy-Hicks training needs analysis (HHTNA) Questionnaire. The survey was distributed by collaborating organizations in Somaliland.RESULTSResponses were received from 41 anaesthesia providers (APs) and 69 surgical providers (SPs), giving a response rate of approximately 59% of APs, 33% of surgeons, and 21% of obstetricians in Somaliland. The HHTNA of APs highlighted that emergency front of neck access (cricothyroidotomy) was a 'high intervention priority' procedure among APs. Regional anaesthesia, medical management of co-morbidities, and anaesthesia in geriatric populations were also considered performance outliers and should also be the focus of further intervention. Importantly, mixed interventions were desired, indicating that training alone would be insufficient, and that improvements to the work situation also need to be addressed.CONCLUSIONThis study has demonstrated that conducting a pragmatic TNA of the surgical team in a low-resource setting, such as Somaliland, is both feasible and can generate useful data to guide training and professional development.","PeriodicalId":136,"journal":{"name":"British Journal of Surgery","volume":"31 1","pages":"xv43-xv49"},"PeriodicalIF":9.6,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145710977","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Thomas Ashley,Hannah F Ashley,Andreas Wladis,Pär Nordin,Michael Ohene-Yeboah,Isaac O Smalle,Jessica H Beard,Jenny Löfgren,Håkon A Bolkan,Alex J van Duinen
BACKGROUNDInguinal hernia repair is one of the most performed surgical procedures, but, nevertheless, there is a high unmet need, with over 200 million people worldwide living with an inguinal hernia. The aims of this study were to evaluate 5-year outcomes after anterior mesh inguinal hernia repair, to assess the safety of a training intervention, and to compare the outcomes of patients operated on by a medical doctor (MD) versus an associate clinician (AC).METHODSAdult men with a primary inguinal hernia were included either as training patients or in the randomized trial, with surgical treatment performed by an MD or an AC. Patients were followed up mostly at hospital or at home; questionnaire information was collected and physical examinations were performed. Outcomes of training and trial patients were compared and outcomes of patients who underwent surgeries performed by MDs or ACs during the trial were compared.RESULTSIn total, 129 patients were included in the training group and 229 patients were included in the randomized trial group. At 5-year follow-up, 288 patients (80.4%) were alive, 40 patients (11.2%) had died, and 30 patients (8.4%) were lost to follow-up. The overall recurrence rate was 5.0% and the all-cause mortality rate was 11.2%. Mortality and recurrence were not significantly different between the training and trial patients or between the patients who underwent surgeries performed by MDs or ACs during the trial.CONCLUSIONLong-term outcomes after primary elective inguinal mesh hernia repair indicate that hands-on short-course training can be implemented effectively and that task sharing is safe and effective.
{"title":"Outcomes after elective inguinal hernia repair with mesh performed by associate clinicians versus medical doctors in Sierra Leone: 5-year follow-up of a randomized clinical trial.","authors":"Thomas Ashley,Hannah F Ashley,Andreas Wladis,Pär Nordin,Michael Ohene-Yeboah,Isaac O Smalle,Jessica H Beard,Jenny Löfgren,Håkon A Bolkan,Alex J van Duinen","doi":"10.1093/bjs/znaf221","DOIUrl":"https://doi.org/10.1093/bjs/znaf221","url":null,"abstract":"BACKGROUNDInguinal hernia repair is one of the most performed surgical procedures, but, nevertheless, there is a high unmet need, with over 200 million people worldwide living with an inguinal hernia. The aims of this study were to evaluate 5-year outcomes after anterior mesh inguinal hernia repair, to assess the safety of a training intervention, and to compare the outcomes of patients operated on by a medical doctor (MD) versus an associate clinician (AC).METHODSAdult men with a primary inguinal hernia were included either as training patients or in the randomized trial, with surgical treatment performed by an MD or an AC. Patients were followed up mostly at hospital or at home; questionnaire information was collected and physical examinations were performed. Outcomes of training and trial patients were compared and outcomes of patients who underwent surgeries performed by MDs or ACs during the trial were compared.RESULTSIn total, 129 patients were included in the training group and 229 patients were included in the randomized trial group. At 5-year follow-up, 288 patients (80.4%) were alive, 40 patients (11.2%) had died, and 30 patients (8.4%) were lost to follow-up. The overall recurrence rate was 5.0% and the all-cause mortality rate was 11.2%. Mortality and recurrence were not significantly different between the training and trial patients or between the patients who underwent surgeries performed by MDs or ACs during the trial.CONCLUSIONLong-term outcomes after primary elective inguinal mesh hernia repair indicate that hands-on short-course training can be implemented effectively and that task sharing is safe and effective.","PeriodicalId":136,"journal":{"name":"British Journal of Surgery","volume":"39 1","pages":"xv50-xv57"},"PeriodicalIF":9.6,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145710978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The year 2015 was a landmark year for global surgical care due to the publication of the 2030 targets of the Lancet Commission on Global Surgery. The Lancet report catalysed the global surgery movement amidst warnings of the movement's fragmentation, exclusivity, and leaning towards the Global North. Since then, there has been positive growth in academic global surgery programmes and centres, surgery coalitions, student advocacy, infrastructure, and task-sharing models, and a shift in the framing of global surgery from brief north-south mission trips to an academic discipline with burgeoning literature. Since 2016, four of the commission's six indicators have been integrated into the World Development Indicators. However, there has been a significant decline in the national reporting of these indicators (in some instances to 0% globally), making it difficult to objectively assess progress. The aim of this article is to discuss the progress and controversies surrounding the commission's benchmarks for specialist surgical workforce density, geographical access to surgical care, financial risk protection for surgical care, and surgical volume and reporting of perioperative mortality, as well as to discuss some unintended consequences since the commission, including the challenge of negative framing, the creation of a surgeon-focused movement, the expansion of a largely academic field with little focus on implementers, emphasis on high-level advocacy without a similar focus on grassroots advocacy, hyper-emphasis on surgical plans without appropriate focus on implementation capacity, relegation of community-based care and prevention as a component of global surgery, and the challenge of the use of 10-year-old data, 5 years to the finish line. Finally, broad recommendations for progress are suggested using a nine-pronged framework.
{"title":"Five years to the finish line: progress and unintended consequences since the Lancet Commission on Global Surgery.","authors":"Barnabas T Alayande,Abebe Bekele","doi":"10.1093/bjs/znaf205","DOIUrl":"https://doi.org/10.1093/bjs/znaf205","url":null,"abstract":"The year 2015 was a landmark year for global surgical care due to the publication of the 2030 targets of the Lancet Commission on Global Surgery. The Lancet report catalysed the global surgery movement amidst warnings of the movement's fragmentation, exclusivity, and leaning towards the Global North. Since then, there has been positive growth in academic global surgery programmes and centres, surgery coalitions, student advocacy, infrastructure, and task-sharing models, and a shift in the framing of global surgery from brief north-south mission trips to an academic discipline with burgeoning literature. Since 2016, four of the commission's six indicators have been integrated into the World Development Indicators. However, there has been a significant decline in the national reporting of these indicators (in some instances to 0% globally), making it difficult to objectively assess progress. The aim of this article is to discuss the progress and controversies surrounding the commission's benchmarks for specialist surgical workforce density, geographical access to surgical care, financial risk protection for surgical care, and surgical volume and reporting of perioperative mortality, as well as to discuss some unintended consequences since the commission, including the challenge of negative framing, the creation of a surgeon-focused movement, the expansion of a largely academic field with little focus on implementers, emphasis on high-level advocacy without a similar focus on grassroots advocacy, hyper-emphasis on surgical plans without appropriate focus on implementation capacity, relegation of community-based care and prevention as a component of global surgery, and the challenge of the use of 10-year-old data, 5 years to the finish line. Finally, broad recommendations for progress are suggested using a nine-pronged framework.","PeriodicalId":136,"journal":{"name":"British Journal of Surgery","volume":"55 1","pages":"xv3-xv9"},"PeriodicalIF":9.6,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145710960","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
BACKGROUNDIn many low- and middle-income countries (LMICs), domestic investments to strengthen surgical services compete with services delivered by international missions. While addressing the high burden of unmet surgical need is a priority, there remains limited evidence on the comparative economic value of different delivery options to guide investment decisions.METHODSFour databases and grey literature were searched for publications in any language from January 2013 to January 2023. Eligible studies evaluated the cost-effectiveness, cost-utility, or cost-benefit of international missions and domestic initiatives used for scale up of surgical care. Average cost-effectiveness ratios were computed for each intervention and then converted to 2022 international dollars (I$). Findings were synthesized narratively.RESULTSA total of 32 studies were identified (17 studies evaluated domestic surgical system strengthening programmes, 14 studies assessed international missions, and 1 study directly compared a domestic surgical development initiative against international missions). Financial protection schemes, investments in physical infrastructure, surgical residency training, and local missions were cost-effective, as were most of the international missions, compared with status quo or no intervention. However, when compared head-to-head, the unit costs per disability-adjusted life-year averted of domestic initiatives were significantly lower relative to the international missions-mean (standard deviation) I$27 051 (I$65 360) and median (interquartile range) I$498 (I$602) versus mean (standard deviation) I$515 500 (I$1 528 716) and median (interquartile range) I$5068 (I$31 618). The difference was statistically significant (Wilcoxon rank-sum test: z = 2.412; P = 0.016).CONCLUSIONInvestments in domestic surgical system strengthening efforts provide better value for money than international missions and should be prioritized over international missions.
背景在许多低收入和中等收入国家，加强外科手术服务的国内投资与国际特派团提供的服务存在竞争。虽然解决未满足手术需求的高负担是一个优先事项，但关于不同交付选择的比较经济价值来指导投资决策的证据仍然有限。方法检索4个数据库和灰色文献，检索2013年1月至2023年1月所有语种的出版物。符合条件的研究评估了用于扩大外科护理规模的国际任务和国内倡议的成本效益、成本效用或成本效益。计算每项干预措施的平均成本效益比，然后转换为2022年国际美元（I$）。研究结果以叙述的方式综合。结果共纳入32项研究（17项研究评估了国内外科系统加强方案，14项研究评估了国际任务，1项研究直接比较了国内外科发展倡议与国际任务）。与现状或不干预相比，财政保护计划、有形基础设施投资、外科住院医师培训和当地特派团与大多数国际特派团一样具有成本效益。然而，当进行正面比较时，国内计划的每个残疾调整生命年的单位成本明显低于国际任务-平均（标准差）27051美元（65 360美元）和中位数（四分位数范围）498美元（602美元）与平均（标准差）515500美元（1528716美元）和中位数（四分位数范围）5068美元（31 618美元）。差异有统计学意义（Wilcoxon秩和检验：z = 2.412; P = 0.016）。结论加强国内手术系统的投资比国际任务更有价值，应优先于国际任务。
{"title":"Economic value of international missions and domestic initiatives to strengthen surgical care in low- and middle-income countries: systematic review.","authors":"Martilord Ifeanyichi,Yannis Reissis,Rebecca Hakim,Maeve Bognini,Meskerem Kebede,Rachel Hargest,Rocco Friebel","doi":"10.1093/bjs/znaf207","DOIUrl":"https://doi.org/10.1093/bjs/znaf207","url":null,"abstract":"BACKGROUNDIn many low- and middle-income countries (LMICs), domestic investments to strengthen surgical services compete with services delivered by international missions. While addressing the high burden of unmet surgical need is a priority, there remains limited evidence on the comparative economic value of different delivery options to guide investment decisions.METHODSFour databases and grey literature were searched for publications in any language from January 2013 to January 2023. Eligible studies evaluated the cost-effectiveness, cost-utility, or cost-benefit of international missions and domestic initiatives used for scale up of surgical care. Average cost-effectiveness ratios were computed for each intervention and then converted to 2022 international dollars (I$). Findings were synthesized narratively.RESULTSA total of 32 studies were identified (17 studies evaluated domestic surgical system strengthening programmes, 14 studies assessed international missions, and 1 study directly compared a domestic surgical development initiative against international missions). Financial protection schemes, investments in physical infrastructure, surgical residency training, and local missions were cost-effective, as were most of the international missions, compared with status quo or no intervention. However, when compared head-to-head, the unit costs per disability-adjusted life-year averted of domestic initiatives were significantly lower relative to the international missions-mean (standard deviation) I$27 051 (I$65 360) and median (interquartile range) I$498 (I$602) versus mean (standard deviation) I$515 500 (I$1 528 716) and median (interquartile range) I$5068 (I$31 618). The difference was statistically significant (Wilcoxon rank-sum test: z = 2.412; P = 0.016).CONCLUSIONInvestments in domestic surgical system strengthening efforts provide better value for money than international missions and should be prioritized over international missions.","PeriodicalId":136,"journal":{"name":"British Journal of Surgery","volume":"29 1","pages":"xv18-xv29"},"PeriodicalIF":9.6,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145710961","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Controversies and conundrums in global surgery.","authors":"Rachel Hargest,Rocco Friebel","doi":"10.1093/bjs/znaf206","DOIUrl":"https://doi.org/10.1093/bjs/znaf206","url":null,"abstract":"","PeriodicalId":136,"journal":{"name":"British Journal of Surgery","volume":"20 1","pages":"xv1-xv2"},"PeriodicalIF":9.6,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145710983","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Isobel H Marks,Lucy Kanya,Darshita Singh,Raoof Saleh,Rocco Friebel,Rachel Hargest
BACKGROUNDThe international community has, for many years, offered support and medical services at times of conflict, crisis, or disaster, but their ability to do so effectively has come under increasing scrutiny in recent years. The aim of this study was to examine the perceptions of local surgeons to incoming medical teams and international non-governmental organizations (iNGOs) during times of conflict. Non-resident diaspora surgeons who returned during conflict were analysed as a subgroup.METHODSA cross-sectional study using qualitative methods was performed. Study participants were in-country-based medically qualified personnel performing surgery during conflicts in the Middle East and North Africa, who had worked in these settings before the onset or escalation of conflict. Participants were identified through a pre-interview questionnaire distributed via the Royal College of Surgeons of England and other targeted networks. A structured guide was used to conduct in-depth interviews with 21 surgeons from eight countries and a thematic analysis was undertaken.RESULTSLocal surgeons generally had positive working relationships with incoming medical teams, but not universally. Some experienced frustration with inexperienced incoming surgeons and others were limited in interaction due to the nature of the conflict. A need for coordination, timely intervention, and less 'playing the hero' was noted in relation to iNGOs. Diaspora surgeons often played a significant role in supporting local surgeons clinically and via equipment procurement and training.CONCLUSIONIncoming medical teams travelling to conflict areas should be experts in their field and work collaboratively with local surgeons. Increased communication and collaboration between iNGOs and local surgeons is necessary to reduce duplication of effort and improve services.
{"title":"Qualitative perspectives (on incoming medical teams during conflict) from surgeons in the Middle East and North Africa.","authors":"Isobel H Marks,Lucy Kanya,Darshita Singh,Raoof Saleh,Rocco Friebel,Rachel Hargest","doi":"10.1093/bjs/znaf209","DOIUrl":"https://doi.org/10.1093/bjs/znaf209","url":null,"abstract":"BACKGROUNDThe international community has, for many years, offered support and medical services at times of conflict, crisis, or disaster, but their ability to do so effectively has come under increasing scrutiny in recent years. The aim of this study was to examine the perceptions of local surgeons to incoming medical teams and international non-governmental organizations (iNGOs) during times of conflict. Non-resident diaspora surgeons who returned during conflict were analysed as a subgroup.METHODSA cross-sectional study using qualitative methods was performed. Study participants were in-country-based medically qualified personnel performing surgery during conflicts in the Middle East and North Africa, who had worked in these settings before the onset or escalation of conflict. Participants were identified through a pre-interview questionnaire distributed via the Royal College of Surgeons of England and other targeted networks. A structured guide was used to conduct in-depth interviews with 21 surgeons from eight countries and a thematic analysis was undertaken.RESULTSLocal surgeons generally had positive working relationships with incoming medical teams, but not universally. Some experienced frustration with inexperienced incoming surgeons and others were limited in interaction due to the nature of the conflict. A need for coordination, timely intervention, and less 'playing the hero' was noted in relation to iNGOs. Diaspora surgeons often played a significant role in supporting local surgeons clinically and via equipment procurement and training.CONCLUSIONIncoming medical teams travelling to conflict areas should be experts in their field and work collaboratively with local surgeons. Increased communication and collaboration between iNGOs and local surgeons is necessary to reduce duplication of effort and improve services.","PeriodicalId":136,"journal":{"name":"British Journal of Surgery","volume":"29 1","pages":"xv35-xv40"},"PeriodicalIF":9.6,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145711107","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hannah B H Wild,Amila Ratnayake,S Yves G Sanou,Yves Aziz R Nacanabo,Akeza A Asgedom,Khalifa Lawan,Aparna Cheran,Selwyn O Rogers,Albert I Ko,Nicolas Meda,Sherry M Wren
{"title":"Barriers perpetuating the lack of casualty data from neglected conflict settings.","authors":"Hannah B H Wild,Amila Ratnayake,S Yves G Sanou,Yves Aziz R Nacanabo,Akeza A Asgedom,Khalifa Lawan,Aparna Cheran,Selwyn O Rogers,Albert I Ko,Nicolas Meda,Sherry M Wren","doi":"10.1093/bjs/znaf223","DOIUrl":"https://doi.org/10.1093/bjs/znaf223","url":null,"abstract":"","PeriodicalId":136,"journal":{"name":"British Journal of Surgery","volume":"28 1","pages":"xv58-xv59"},"PeriodicalIF":9.6,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145710980","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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