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ObjectivesAlthough timely surgery is essential for improving general health and psychosocial outcomes, delays in cleft surgery remain common in low- and middle-income countries, including Rwanda, where little is known about the underlying causes. This study aimed to explore the factors influencing delays in cleft surgery in Rwanda using the four-delay framework.DesignA phenomenological qualitative study was conducted between April and July 2024. We conducted 29 in-depth interviews with 15 caregivers of children with orofacial clefts and 14 healthcare providers involved in cleft care. Transcripts were analysed thematically using an inductive–deductive hybrid approach in MAXQDA (V.24), guided by the four-delay framework while allowing themes to emerge from the data.SettingThis qualitative study was conducted across six Operation Smile-supported hospitals in Rwanda. Operation Smile is a non-governmental organisation providing cleft care in several low- and middle-income countries, including Rwanda. Among these facilities, one is a tertiary-level hospital located in Kigali city, while the others are secondary-level hospitals distributed across all provinces of the country.ParticipantsParticipants were purposively selected and comprised caregivers of children who underwent cleft surgery at Operation Smile-supported hospitals between 2023 and 2024, as well as healthcare providers with a minimum of 6 months’ experience delivering cleft care at these facilities.ResultsSix major themes and 15 subthemes emerged. Limited caregiver awareness, cultural beliefs and inconsistent knowledge of clefts among healthcare providers influenced delays in seeking care. Reaching care was impeded by long distances, poor road infrastructure and inadequate transportation options. Receiving care was delayed by patient-related factors such as poor nutritional status of children and systemic issues, including shortages of specialised cleft care workforce (such as plastic surgeons, oral and maxillofacial surgeons, anaesthesiologists, etc) and surgical infrastructure. Remaining in care was affected by the absence of multidisciplinary follow-up services. Despite these barriers, caregivers appreciated the support services provided by Operation Smile, including nutrition, transportation and coverage of surgery costs.ConclusionsCleft surgery delays in Rwanda are driven by multifactorial barriers across all stages of care. Strengthening early identification, public awareness, health provider training and post-operative support systems is essential to reducing delays and improving outcomes. Findings support the need for integrated cleft care within national surgical plans and broader health system strengthening efforts, and encourage the social and psychological support to affected children and caregivers.

Introduction Although the recent expansion of pediatric surgical services in Rwanda has improved patient outcomes, pediatric surgery specialists are available only at referral hospitals. Children with surgical conditions are often first evaluated by non-specialist physicians at district or regional hospitals prior to definitive transfer. Knowledge gaps exist in the initial management of pediatric surgical conditions among non-specialist physicians. This study assesses the impact of a needs-directed short course for non-specialist physicians in Rwanda. Methods Nine prioritized pediatric surgical conditions were identified through an expert-led modified two-stage Delphi. Course content was created to fill knowledge gaps, determined through a needs assessment. Pediatric surgeons and local trainees delivered the course to non-specialist physicians at five district and regional hospitals. Participant reactions and knowledge were analyzed using RStudiov1.1.4, and thematic analysis was performed on free text responses. Results Fifty-nine non-specialist physicians with heterogeneous experience participated. Participants rated the course highly, and self-rated knowledge and confidence increased on all conditions. Overall knowledge-based scores and initial management for all conditions improved substantially. More participants indicated that they knew how to contact a member of the pediatric surgical team after the course. Positive themes included acquisition of knowledge that was relevant to practice, effective course execution, and the interactive nature of the course. Themes for improvement centered on desire for more content and course availability. Conclusions As pediatric surgical capacity improves, safe initial management is critical. A novel, needs-directed short course for non-specialist physicians appears to be an effective way to address knowledge gaps and improve the referral process through direct connection with specialists. Providing such a course on a regular basis to senior medical students and new graduates is a promising avenue to improving the provision of safe, timely pediatric surgical care.

IntroductionWhile philanthropy, multilateral support and innovative internal funding approaches remain important to address surgical healthcare needs, there is increasing demand for efficiency models that maximise the impact of available resources. Cost-saving strategies are attractive to governments. We sought to answer the scoping review question: ‘What are documented and transferable system-level cost-saving strategies in the provision of surgical healthcare services applicable in limited-resource settings?’MethodsThe scoping review was guided by the Arksey and O’Malley framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines; 642 studies were screened from PubMed, EMBASE, Global Index Medicus, Africa Journals Online and Google Scholar (2015–2024), without language or article type restrictions. Following title, abstract and full-text screening by 2 independent reviewers, we identified 63 records that met inclusion criteria: documented cost-saving strategies in surgical systems from community to national levels. Strategies were extracted into a theoretical framework adapted from the Procter and Gamble’s cost optimisation model and the Triple Aim Framework using Jabareen’s eight-step method.ResultsMost literature on cost savings for surgical healthcare was from high-income countries (81%), at national levels (48%), and focused on orthopaedic/cardiothoracic/vascular surgery. Most (25%) were retrospective observational studies or economic modelling (21%). We synthesised 125 distinct cost-saving strategies into 32 transferable strategies across five thematic areas, prioritised using a sustainability and scalability lens—preventative healthcare management (9%), surgical healthcare guidelines and pathways (31%), payment model transformation (19%), lean principles (25%) and technology adoption (16%). Strategies focused on governance, standardisation and process redesign were more likely to be sustainable and scalable with minimal resources, whereas interventions requiring coordinated delivery models or advanced digital infrastructure were more scale-dependentConclusionsWe identified an integrated portfolio of contextualisable surgical cost-saving strategies that eliminate system waste, improve efficiency and result in savings. Policymakers and health system stakeholders in low-income and middle-income countries can use this structured evidence to prioritise, implement and scale cost-saving strategies.

Background An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy and assessed first-time user experience. Methods An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy for approximately $4.40 USD. Components include medical-grade gelatin, Jell-O™, water, olives, and surgical gloves. The model was used to train two cohorts comprising 30 students total during their junior surgical clerkship. The learners’ experience and perceptions on the first Kirkpatrick level were evaluated using pre- and post-training surveys. Results Response rate was 93.3% ( n  = 28). Only three students had previously completed an ultrasound-guided breast biopsy, and none had prior exposure to simulation-based breast biopsy training. Learners that were confident in performing biopsies under minimal supervision rose from 4 to 75% following the session. All students indicated the session increased their knowledge, and 71% agreed that the model was an anatomically accurate and appropriate substitute to a real human breast. Conclusions The use of a low-cost gelatin-based breast model was able to increase student confidence and knowledge in performing ultrasound-guided breast biopsies. This innovative simulation model provides a cost-effective and more accessible means of simulation-based training especially for low- and middle-income settings.

Introduction While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda. Methods We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05. Results Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91). Conclusion Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Introduction Women who deliver via cesarean section (c-section) experience short- and long-term disability that may affect their physical health and their ability to function normally. While clinical complications are assessed, postpartum functional outcomes are not well understood from a patient’s perspective or well-characterized by previous studies. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30. Methods Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities; and each domain was rated on a 4-point likert scale, lower scores reflecting higher level of difficulties. Using the four functionality domains, we computed composite mean scores with a maximum score of 4.0 and we defined poor functionality as composite score of ≤ 2.0. We assessed functionality with descriptive statistics and logistic regression. Results Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30–45 min had higher odds of poor functionality (aOR = 1.85, p  = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, 95% CI (1.09, 25.57), p  = 0.037). High income patients had incrementally lower significant odds of poor physical functionality (aOR = 0.62 for every US$1 increase in monthly income, 95% CI (0.40, 0.96) p  = 0.04). Conclusion We found a high proportion of poor physical functionality 30 days post-c-section in this Rwandan cohort. Surgery lasting > 30 min and intra-operative complications were associated with poor functionality, whereas a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.

Background Inadequate trauma care training opportunities exist in Low- and Middle-Income Countries. Jos University Teaching Hospital and the West African College of Surgeons (WACS) have synergized, over the past 15 years, to introduce a yearly, certified, multidisciplinary Trauma Management Course. We explore the history and evolution of this course. Methods A desk review of course secretariat documents, registration records, schedules, pre- and post-course test records, post-course surveys, and account books complemented by organizer interviews was carried out to elaborate the evolution of the Trauma Management Course. Results The course was started as a local Continuing Medical Education program in 2005 in response to recurring cycles of violence and numerous mass casualty situations. Collaborations with WACS followed, with inclusion of the course in the College’s yearly calendar from 2010. Multidisciplinary faculty teach participants the concepts of trauma care through didactic lectures, group sessions, and hands-on simulation within a one-week period. From inception, there has been a 100% growth in lecture content (from 15 to 30 lectures) and in multidisciplinary attendance (from 23 to 133 attendees). Trainees showed statistically significant knowledge gain yearly, with a mean difference ranging from 10.1 to 16.1% over the past 5 years. Future collaborations seek to expand the course and position it as a catalyst for regional emergency medical services and trauma registries. Conclusions Multidisciplinary trauma management training is important for expanding holistic trauma capacity within the West African sub-region. The course serves as an example for Low- and Middle-Income contexts. Similar contextualized programs should be considered to strengthen trauma workforce development.

Coloniality in global health manifests as systemic inequalities, not based on merit, that benefit one group at the expense of another. Global surgery seeks to advance equity by inserting surgery into the global health agenda; however, it inherits the biases in global health. As a diverse group of global surgery practitioners, we aimed to examine inequities in global surgery. Using a structured, iterative, group Delphi consensus-building process drawing on the literature and our lived experiences, we identified five categories of non-merit inequalities in global surgery. These include Western epistemology, geographies of inequity, unequal participation, resource extraction, and asymmetric power and control. We observed that global surgery is dominated by Western biomedicine, characterised by the lack of interprofessional and interspecialty collaboration, incorporation of Indigenous medical systems, and social, cultural, and environmental contexts. Global surgery is Western-centric and exclusive, with a unidirectional flow of personnel from the Global North to the Global South. There is unequal participation by location (Global South), gender (female), specialty (obstetrics and anaesthesia) and profession (‘non-specialists’, non-clinicians, patients and communities). Benefits, such as funding, authorship and education, mostly flow towards the Global North. Institutions in the Global North have disproportionate control over priority setting, knowledge production, funding and standards creation. This naturalises inequities and masks upstream resource extraction. Guided by these five categories, we concluded that shifting global surgery towards equity entails building inclusive, pluralist, polycentric models of surgical care by providers who represent the community, with resource controlled and governance driven by communities in each setting.

Introduction The College of Surgeons of East, Central, and Southern Africa (COSECSA) training program requires completion of a mandatory rotation in vascular and cardiothoracic surgery. However, few accredited training sites offer such services regularly, hence exposure of trainees to these disciplines is limited. This study evaluates the demand, feasibility, and acceptance of an open-access, synchronous virtual surgical education series to bridge gaps in training. Methods The Center for Equity in Global Surgery at the University of Global Health Equity partnered with COSECSA to develop and deliver interactive sessions on common cardiothoracic, vascular, and transplant surgical topics facilitated by faculty from the COSECSA region and global partner institutions. All sessions were delivered via a cloud-based video conferencing service and recorded for retrospective viewing. At the end of the lecture series, trainees participated in a post-course evaluation survey. Results In total, 2,015 participants from 48 countries attended the lecture series with 977 participants in 2022 and 1,038 in 2023. In 2023, most participants were from Ethiopia (10.9%), Kenya (23.6%), and Uganda (15.4%). Two hundred and fifty-two participants contributed to the post-course evaluation survey, of which only 23% were female and 48% were general surgery trainees. Mean satisfaction with the lecture series on a 5-point Likert scale was 4.5. Participants reported an average satisfaction level of 4.4 for logistics of the series (registration process, ease of connectivity, and time management), 4.5 for content, 4.4 for in-class interactions, 4.4 for use of case-based images, and 4.2 for post-session availability of lecture material. Almost all suggested additional lectures in thoracic infection, vascular trauma, and plastic surgery to be included in subsequent lecture series. Conclusion The study has shown that such an online, synchronous, virtual teaching series is in high demand, feasible, and crucial for closing knowledge gaps in didactic cardiothoracic, vascular, and transplant surgery within the COSECSA region. These sessions are well received by COSECSA trainees and are accessible, highlighting a clear demonstrable need. It is recommended that such efforts be sustained and expanded, with additional competency areas to broaden the impact.