Improving Access to Surgery Through Surgical Team Mentoring – Policy Lessons From Group Model Building With Local Stakeholders in Malawi

Document Type : Original Article


1 Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands

2 Department of Health and Society, Wageningen University and Research, Wageningen, The Netherlands

3 College of Medicine, Blantyre, Malawi

4 Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland

5 Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland


There is much scope to empower district hospital (DH) surgical teams in low- and middle- income countries to undertake a wider range and a larger number of surgical procedures so as to make surgery more accessible to rural populations and decrease the number of unnecessary referrals to central hospitals (CHs). For surgical team mentoring in the form of field visits to be undertaken as a routine activity, it needs to be embedded in the local context. This paper explores the complex dimensions of implementing surgical team mentoring in Malawi by identifying stakeholder-sourced scenarios that fit with, among others, national policy and regulations, incentives to perform surgery, career opportunities, competing priorities, alternatives for performing surgery locally and the proximity and role of referral hospitals.

A mixed methods approach was used which combined stakeholder input – obtained through two group model building (GMB) workshops and further consultations with local stakeholders and SURG-Africa project staff – and dynamic modeling to explore policy options for sustaining and rolling out surgical team mentoring. Sensitivity analyses were also performed.

Each of the two GMB workshops resulted in a causal loop diagram (CLD) with an array of factors and feedback loops describing the complexity of surgical team mentoring. Six implementation scenarios were defined to perform such mentoring. For each the resource requirements were identified for the institutions involved – notably DHs, CHs and the party that would finance the required mentoring trips – along with the potential for scaling up surgery at DHs under severe financial constraints.
To sustain surgical mentoring, it is important that an approach of continued communication, monitoring, and (re-)evaluation is taken. In addition, an output- or performance-based financing scheme for DHs is required to incentivize them to scale up surgery.



Commentaries Published on this Paper


  • Improving District Hospital Surgical Capacity in Resource Limited Settings: Challenges and Lessons From South Africa; Comment on “Improving Access to Surgery through Surgical Team Mentoring – Policy Lessons From Group Model Building with Local Stakeholders in Malawi”

        Abstract | PDF


  • Evidence-Driven Policies for Sustainably Scaling Up Surgical Task-Sharing in Malawi; Comment on “Improving Access to Surgery Through Surgical Team Mentoring – Policy Lessons From Group Model Building With Local Stakeholders in Malawi”

        Abstract | PDF


  •  An Urgent Need for a Common Framework for the Articulation, Design and Reporting of Surgical System Strengthening Interventions; Comment on “Improving Access to Surgery Through Surgical Team Mentoring – Policy Lessons From Group Model Building With Local Stakeholders in Malawi”

        Abstract | PDF


  •  Lessons for the Implementability and Sustainability of the SURG-Africa Model of Malawi in Colombia; Comment on “Improving Access to Surgery Through Surgical Team Mentoring – Policy Lessons From Group Model Building With Local Stakeholders in Malawi”

        Abstract | PDF


  • Beyond Policy: Strengthening District Level Access to Surgery Is Critical to Achieving Surgical Equity in Universal Health Coverage; Comment on “Improving Access to Surgery Through Surgical Team Mentoring – Policy Lessons From Group Model Building With Local Stakeholders in Malawi”

        Abstract | PDF



  1. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. doi:10.1016/s0140-6736(15)60160-x
  2. Eyal N, Cancedda C, Kyamanywa P, Hurst SA. Non-physician clinicians in sub-Saharan Africa and the evolving role of physicians. Int J Health Policy Manag. 2015;5(3):149-153. doi:10.15171/ijhpm.2015.215
  3. van Heemskerken P, Broekhuizen H, Gajewski J, Brugha R, Bijlmakers L. Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa-a scoping review. Hum Resour Health. 2020;18(1):51. doi:10.1186/s12960-020-00490-y
  4. Gajewski J, Wallace M, Pittalis C, et al. Why do they leave? challenges to retention of surgical clinical officers in district hospitals in Malawi. Int J Health Policy Manag. 2020. doi:10.34172/ijhpm.2020.142
  5. 5 Muula AS. Case for clinical officers and medical assistants in Malawi. Croat Med J. 2009;50(1):77-78. doi:10.3325/cmj.2009.50.77
  6. Pittalis C, Brugha R, Crispino G, et al. Evaluation of a surgical supervision model in three African countries-protocol for a prospective mixed-methods controlled pilot trial. Pilot Feasibility Stud. 2019;5:25. doi:10.1186/s40814-019-0409-6
  7. Mwapasa G, Pittalis C, Clarke M, et al. Evaluation of a managed surgical consultation network in Malawi. World J Surg. 2021;45(2):356-361. doi:10.1007/s00268-020-05809-3
  8. Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013;8:117. doi:10.1186/1748-5908-8-117
  9. Gajewski J, Mwapasa G, Cheelo M, et al. Participatory action research to design a surgical training and supervision intervention for district level hospitals in Malawi, Tanzania and Zambia. In: International Society of Surgery 2019 Abstract 126.09.
  10. Harvey N, Holmes CA. Nominal group technique: an effective method for obtaining group consensus. Int J Nurs Pract. 2012;18(2):188-194. doi:10.1111/j.1440-172X.2012.02017.x
  11. Pittalis C, Brugha R, Bijlmakers L, Mwapasa G, Borgstein E, Gajewski J. Patterns, quality and appropriateness of surgical referrals in Malawi. Trop Med Int Health. 2020;25(7):824-833. doi:10.1111/tmi.13406
  12. Maine RG, Kajombo C, Mulima G, et al. Secondary overtriage of trauma patients to a central hospital in Malawi. World J Surg. 2020;44(6):1727-1735. doi:10.1007/s00268-020-05426-0
  13. Ifeanyichi M, Broekhuizen H, Cheelo M, et al. Surgical ambulance referrals in sub-Saharan Africa – Financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia. BMC Health Services Research. 2021;21:728. doi:10.1186/s12913-021-06709-5
  14. Bijlmakers L, Cornelissen D, Cheelo M, et al. The cost of providing and scaling up surgery: a comparison of a district hospital and a referral hospital in Zambia. Health Policy Plan. 2018;33(10):1055-1064. doi:10.1093/heapol/czy086
  15. Greenhalgh T, Papoutsi C. Studying complexity in health services research: desperately seeking an overdue paradigm shift. BMC Med. 2018;16(1):95. doi:10.1186/s12916-018-1089-4
  16. Chandler J. The paradox of intervening in complex adaptive systems comment on "using complexity and network concepts to inform healthcare knowledge translation". Int J Health Policy Manag. 2018;7(6):569-571. doi:10.15171/ijhpm.2018.05