Using Group Model Building to Capture the Complex Dynamics of Scaling Up District-Level Surgery in Arusha Region, Tanzania

Document Type : Original Article


1 Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands

2 Department of Business Administration, Institute for Management Research, Radboud University, Nijmegen, The Netherlands

3 Institute of Global Surgery, Royal College of Surgeons Ireland, Dublin 2, Ireland

4 Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland

5 East Central and Southern Africa Health Community, Arusha, Tanzania

6 Tanzania Surgical Association, Dar Es Salaam, Tanzania

7 Kilimanjaro Christian Medical Centre, Moshi, Tanzania


Scaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach.
A group model building (GMB) workshop was held with 18 professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model.
The CLD consists of 57 variables. These include the 48 variables that were obtained through the nominal group technique and those that participants added later. We identified 6 themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are 5 self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or ‘resistors to change:’ recurrent costs, income lost, staff stress, and brain drain.
This study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of ‘quick fixes’ that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner.


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Volume 11, Issue 7
July 2022
Pages 981-989
  • Receive Date: 15 February 2020
  • Revise Date: 30 November 2020
  • Accept Date: 01 December 2020
  • First Publish Date: 14 December 2020