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”

Document Type : Commentary


1 Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA

2 Rutgers Global Health Institute, Rutgers University, New Brunswick, NJ, USA


Nearly 60% of the world’s inhabitants lack access to timely, safe, and ffordable emergency and essential surgical, anesthetic, and obstetric (SAO) services when needed. Although acknowledged as an important step in resolving this disparity, situation analysis informed development of national surgical, obstetric and anesthesia plans (NSOAPs) has not been performed widely. There are even fewer published examples of NSOAP driven SAO system vulnerability resolving policy interventions, potentially hindering broader acceptance and drafting. Thus, there is urgent need for alignment of academic global surgery activities through a common framework for SAO strengthening intervention articulation, design and reporting which can be informed by the Malawian experience and others. This is a logical next step in the evolution of surgical system science as we move towards the articulation of actionable inequity resolving interventions through stakeholder engagement embedded in a plan-do-study-act (PDSA) model for iterative refinement of strengthening policies.


  1. Broekhuizen H, Ifeanyichi M, Mwapasa G, et al. Improving access to surgery through surgical team mentoring-policy lessons from group model building with local stakeholders in Malawi. Int J Health Policy Manag. 2021. doi:34172/ijhpm.2021.78
  2. 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:1016/s0140-6736(15)60160-x
  3. World Health Organization (WHO). Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies. WHO; 2010.
  4. Raykar NP, Ng-Kamstra JS, Bickler S, et al. New global surgical and anaesthesia indicators in the World Development Indicators dataset. BMJ Glob Health. 2017;2(2):e000265. doi:1136/bmjgh-2016-000265
  5. Binda C, Zivkovic I, Duffy D, Blair G, Baird R. Evaluation of interventions addressing timely access to surgical care in low-income and low-middle-income countries as outlined by the LANCET Commission 2030 global surgery goals: a systematic review. World J Surg. 2021;45(8):2386-2397. doi:1007/s00268-021-06152-x
  6. Doran GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Manage Rev. 1981;70(11):35-36.
  7. Deming WE. Out of the Crisis. The MIT Press; 1986.
  8. Albutt K, Citron I, Johnson W, et al. National Surgical, Obstetric and Anaesthesia Planning Manual (2020 Edition). Published September 28, 2020. doi:5281/zenodo.3982869
  9. Peck GL, Hanna JS. The National Surgical, Obstetric, and Anesthesia Plan (NSOAP): Recognition and Definition of an Empirically Evolving Global Surgery Systems Science Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa". Int J Health Policy Manag. 2018;7(12):1151-1154. doi:15171/ijhpm.2018.87
  10. Evaluation Briefs: Writing SMART Objectives. Published November 21, 2018.
  11. Gajewski J, Borgstein E, Bijlmakers L, et al. Evaluation of a surgical training programme for clinical officers in Malawi. Br J Surg. 2019;106(2):e156-e165. doi:1002/bjs.11065
  12. Ashengo T, Skeels A, Hurwitz EJH, Thuo E, Sanghvi H. Bridging the human resource gap in surgical and anesthesia care in low-resource countries: a review of the task sharing literature. Hum Resour Health. 2017;15(1):77. doi:1186/s12960-017-0248-6
  13. Nepogodiev D, Martin J, Biccard B, Makupe A, Bhangu A. Global burden of postoperative death. Lancet. 2019;393(10170):401. doi:1016/s0140-6736(18)33139-8
  14. McCrum ML, Valmont T, Price RR. Developing a surgical quality improvement program for resource-limited settings. JAMA Surg. 2020;155(12):1160-1161. doi:1001/jamasurg.2020.4347
  15. Grimes CE, Quaife M, Kamara TB, Lavy CBD, Leather AJM, Bolkan HA. Macroeconomic costs of the unmet burden of surgical disease in Sierra Leone: a retrospective economic analysis. BMJ Open. 2018;8(3):e017824. doi:1136/bmjopen-2017-017824
Volume 11, Issue 11
November 2022
Pages 2755-2758
  • Receive Date: 07 December 2021
  • Revise Date: 07 April 2022
  • Accept Date: 09 April 2022
  • First Publish Date: 10 April 2022