Kigali — In many parts of the world, particularly in Africa, access to safe, affordable, and timely surgical care remains a significant challenge. Yet, despite these challenges, the potential for transformation exists – a potential that can be unlocked through regional partnerships, local expertise, and global collaboration.
This was the focus of the session titled “Local, Regional, and Global Collaborations for Advancing Surgery Across Africa,” held at the Pan African Surgical Conference in Rwanda. The session brought together a group of leaders who are at the forefront of advancing surgical care on the continent. Their work exemplifies the power of collaboration in overcoming barriers and improving patient outcomes, offering hope and actionable solutions for the future.
Panelists:
Dr. Robert Riviello: Medical Director of the Metabolic Support Service and Associate Surgeon with the Division of Trauma, Burn, and Surgical Critical Care at Brigham and Women’s Hospital (Moderator)
Dr. Peter Ntumba: Plastic and Reconstructive Surgeon from Kenya, Head of Department and Programme Director, Founder of Beach Research (an initiative mentoring medical students in surgical careers)
Professor Florent Rutagarama: Pediatrician and Pediatric Endocrinologist, Dean of the School of Medicine and Pharmacy at Vanderbilt, Leader in Child Health
Dr. Glory Msibi: President of the East, Central, and Southern Africa College of Nursing and Midwives (ECSACONM), with over 22 years of experience as a Chief Nursing Officer
Dr. Stephen Okelo: Anesthesiologist and Educator, President of the Kenya Society of Anesthesiologists (KSA) and the College of Anesthesiologists of East, Central, and Southern Africa (CANECSA), Member of the WHO Technical Advisory Group for Integrated Clinical Care
Professor Stella Itungu: Chief Executive Officer of the College of Surgeons of East, Central, and Southern Africa (COSECSA), known for transforming the organization
Dr. Jane Fulal: Experienced General Surgeon specializing in Endocrine and Breast Surgery, with over 26 years and thousands of successful operations
Dr. Andrea Pusic: Chief of Plastic and Reconstructive Surgery at Brigham and Women’s Hospital, Pioneer in Patient-Reported Outcomes Research
Professor Salome Maswime: OBGYN, Head of the Global Surgery Mission at the University of Cape Town, Leader in Innovative Training and Research Programs in Global Surgery
Together, these experts brought a wealth of knowledge, experience, and dedication to improving surgical care worldwide, addressing three critical questions: What are the barriers to effective collaboration? How can we collaborate successfully? And how will we know if our collaborations are successful?
“One of my biggest disappointments is the fact that we do not have, as global surgery advocates, we do not have a structure. We do not have a leadership. We do not have a representation,” said Dr. Ntumba. He said that lack of coordination leads to “a lot of wasted resources, a lot of duplication of function and work, and therefore, massive waste.” He pointed out the uneven distribution of surgical NGOs, with many operating in the same regions or countries, leading to inefficiencies.
To address these challenges, Dr. Ntumba proposed the creation of a centralized office at the World Health Organization dedicated to scaling up surgical efforts, where surgical NGOs could collaborate.
“I’m not suggesting people give up their independence, but rather that they come into the same space, contribute, and agree on where resources need to be spent,” he said.”Without a clear blueprint, it is impossible to know where to act; LMICs should be required to develop their own National Surgical, Obstetric, and Anesthesia Plans (NSOPs) to guide their actions.”
Ntumba identified challenges such as a lack of authenticity and transparency in collaborative efforts, and questioning what each party brings to the table.
“Creating solutions is key to overcoming them.”
“The first step is events like this one… sitting together and talking about our own challenges and putting in place solutions on how we can address those challenges,” said Rutagarama.
Professor Rutagarama said that many African countries struggle with inadequate resources, making it difficult to collaborate effectively with international colleagues. “We have been experiencing scarcity in almost everything, especially hospital infrastructure, equipment, and digital facilitation, and most of the time, we rely on donations,” she said. “Whenever donations are available, there is no maintenance skill, so you remain focused on your own problems and are limited in engaging in collaboration.”
She said political and economic instability exacerbates existing challenges, particularly in war-torn regions where funds are diverted to conflict rather than healthcare, adding that healthcare infrastructure is often concentrated in capital cities, leaving remote areas underserved due to conflict and accessibility issues.
“Brain drain is another problem,” she said.
Rutagarama also addressed the difficulty of retaining trained doctors, as many leave for better opportunities abroad, creating a shortage of skilled professionals to build a strong local healthcare system. “Governments have been investing in training people, but there have been difficulties in retaining those people. Doctors are trained using local resources, but once they graduate, they leave. They go to find a greener pasture where they can get better salaries.” This brain drain, she said, weakens local healthcare systems and limits international collaboration.
Cultural and linguistic diversity also play a role in hindering cooperation, she said. She acknowledged the historical impact of cultural and linguistic diversity on collaboration but said that progress is being made as people now come together to discuss solutions for improving surgery and healthcare.
“In theatre, we work as a team. It’s a multidisciplinary team.”
“Africa is facing so many challenges, particularly in the health sector. However, with a common mind and a common vision, no mountain is insurmountable,” said Dr. Msibi.
Msibi pointed out the importance of teamwork in surgical settings, describing it as a multidisciplinary effort. “Research has proven that post-operatively, 30 days after operation, complications and mortality rates are high. Probably 4.2 million people die post-operatively within 30 days. And why is it happening? It’s because that nursing link is still missing,” she said. “Invest in us. If you invest in training healthcare workers, not necessarily nurses, I think that is part of the solution.”
She said there is a need for investment in training healthcare workers, particularly in specialized roles like peri-operative nursing, to improve surgical outcomes. She also said that weak health systems in Africa are a major barrier to resolving healthcare challenges and called for stronger leadership and policy alignment.
“In most of our regions, you have around two specialized peri-operative nurses in a referral hospital, yet over 1,000 operations are conducted there per month,” Dr. Msibi said. “You cannot give someone to do something they are not specialized in and expect it to be done perfectly and correctly. We need to invest in our healthcare workers – that will be a very good solution.”
“We need policies that address the recruitment and retention of healthcare workers. Otherwise, training will be like pouring water into a sieve – nothing will remain.”
She called for policies to address the recruitment and retention of healthcare workers, warning that without such policies, training efforts would be ineffective.
“Partnerships must focus on strengthening institutions and aligning with local needs to build sustainable surgical services in Africa.”
“If you look at the theme of this meeting, which is building resilient and sustainable surgical services or systems in Africa, to me that is what we should do. We should be talking about the services and the system” said Dr. Okelo, an anesthesiologist.
He said that sending a surgeon to a district is not enough; they require adequate infrastructure, personnel, and support to function effectively. He criticized the lack of coordination in operating rooms, where surgeons, anesthetists, and nurses often work in silos, leading to inefficiencies.
He also warned against a “fly-in, fly-out” or “hit and run” model of global health, where foreign teams perform surgeries and leave without building local capacity. “What we need to focus on is building local capacity and transferring skills,” he said.
Dr. Okelo argued that without proper utilization of resources at the local level, even significant global support would be ineffective, likening it to “boiling the ocean.”
“Partnerships should focus on strengthening institutions rather than just targeting individual projects. If we don’t have a clear plan, external partners will impose their own agendas, which may not align with our country’s actual needs. It’s crucial for us to identify what we need before seeking support, ensuring that any collaboration is in line with our priorities to build local capacity and sustainable surgical services in Africa,” he said.
According to him, governments should take the lead in defining their healthcare needs so that external partners align their support accordingly, rather than imposing predefined solutions. Dr. Okelo called for countries to develop clear plans and identify their needs before engaging with partners, ensuring that collaborations align with national priorities.
“Government support is crucial – it controls the outcomes of our work.”
COSECSA operates in 24 countries throughout Sub-Saharan Africa, with footholds in most hospitals. Professor Itungu acknowledged Operation Smile’s invaluable support as a vital component of their work from training to scholarship programs to surgery workshops.
Government intervention is essential for sustainable surgical collaboration. This includes equipping hospitals, providing resources, making strategic policy decisions, and ensuring that existing institutions are supported. Rwanda benefits from high-level leadership support, recognizing that any health initiative must have government backing to succeed. Without government involvement, our efforts risk being short-lived, she said.
For example, governments establish colleges, but in some countries, graduates find themselves unrecognized despite undergoing government-sanctioned training. This presents a ‘chicken-and-egg’ dilemma: institutions are encouraged to train surgeons, yet their accreditation is not always acknowledged. How do we bridge this gap?
Professor Itungu said that each year, COSECSA receives over 650 applications for its surgical training program. While not all applicants qualify, around 40% are eligible but lack funding. Thanks to Operation Smile and other partners, scholarships have significantly increased access to training.
The impact is evident – plastic surgery procedures once accounted for only 3% of total surgeries; today, they have risen to 7-8%. This demonstrates that increased support translates directly into more surgical procedures and improved patient care.
She said the demand for surgical training exists, but many potential trainees drop out due to financial constraints. She added that they have dedicated professionals and institutions but without adequate support, their reach is limited.
A key question arises: how do we build strong partnerships that bring together institutions, trainees, and funding sources to expand surgical care and ensure access, particularly in underserved areas?
Training is at the heart of a successful surgical ecosystem. Thanks to partnerships, our trainees have opportunities to learn from diverse settings. For instance, we have facilitated training exchanges between Rwanda, Ethiopia, Zambia, and Uganda, allowing surgeons to gain experience in different healthcare environments, she said.
“To date”, said Itungu, “COSECSA has accredited 149 training sites, 46% of which are in rural and semi-urban areas. Rwanda’s Ministry of Health has upgraded 10 district hospitals to level two teaching hospitals, attracting trainees to rural regions.
Our goal was to graduate 1,000 surgeons by 2025. We surpassed this target last year, with 1,048 surgeons trained, 93% of whom remain in the region.”
Dr. Itungu said the importance of defining clear goals and objectives at the outset of any partnership to ensure its success.
“Strong partnerships need clear goals, local ownership, and lasting impact.”
“In any partnership,” said Dr. Fulal, “the importance of clearly defining the objectives and goals, explaining that it is essential to define the goal of the collaboration before it begins.” “When you have partners, the first question is, how do you start? And then, what is your goal? What is your objective for the collaboration?” she said.
Dr. Fulal said that partnerships should not be one-sided but should function as a “bi-directional” effort, where both parties contribute meaningfully. “Ownership of the programs should be there in planning so that nothing dies with these partnerships. Eventually, they exit because memorandums of understanding are for a certain period,” she said.
She said the Royal College of Surgeons in Ireland (RCSI) supported COSECSA by funding its organizational structure, including the establishment of a CEO and Secretariat, to manage projects effectively. According to her, COSECSA’s operations are like operating a “big Titanic,” which requires a strong organizational structure. She stressed the importance of advocacy, policy application, and support in ensuring collaborative success.
“If we work, work, work, and we fail to monitor and evaluate, then we shall not know whether we are doing something successfully or not,” she said. She suggested that regular meetings between partners and local organizations ensure alignment and effective tracking of progress.
COSECSA celebrated its 25th anniversary, and Dr. Fulal thanked all partners for their contributions, saying that the accomplishments of COSECSA were also the accomplishments of its collaborative partners.
“Beyond morbidity and mortality, we should consider patient-centered outcomes.”
“I think there’s an opportunity to leverage health services research and quality improvement methodologies to establish best practices in different settings. We must consider structure, process, and outcomes – ensuring not only that surgeries are safe but also that they meet patient goals, such as improving function or reducing pain. Measuring these outcomes rigorously helps determine healthcare value, especially in resource-limited settings,” said Dr. Pusic.
She said a shift in focus toward outcomes is necessary, particularly patient-centered outcomes like functionality and pain reduction.
“We often assess structure – like the availability of operating rooms – and processes, such as surgical checklists and pre-operative antibiotics. But we also need to focus on outcomes, particularly whether surgery meets patient goals, such as improved function or reduced pain,” she said.
Progress was made in addressing surgical site infections and complications, she said but challenged the field to consider performance quality and whether surgical goals were achieved from the patient’s perspective. Dr. Pusic argued that measuring these outcomes rigorously is not only possible but also crucial for understanding healthcare value, especially in resource-limited settings.
According to Dr. Pusic, evaluating surgical outcomes should not stop at morbidity and mortality rates. “Did the surgery achieve what the patient hoped for? These are measurable and provide valuable insights into healthcare value, especially in resource-limited settings,” she said.
She urged the medical community to measure whether procedures meet patient expectations, such as improving function or alleviating pain, as these factors significantly contribute to healthcare value.
Dr. Pusic concluded by stressing the importance of directing resources toward interventions that deliver the most value to patients.
“Yesterday’s solutions can become tomorrow’s problems.”
“The worst-case scenario is having two parties eager to solve a problem but without an actual problem to address. Too often, partnerships are formed around solutions rather than real needs,” said Professor Maswime. “We celebrate interventions more than solving the actual problem. The key question should be: Did we achieve what we set out to do? Have we truly improved the situation?”
She said that in many cases, interventions are celebrated for their execution rather than their impact. True success, she argued, should be measured by whether the intended beneficiaries experience meaningful improvements.
“Sometimes we choose our solutions based on our own personal interests, based on our own experiences, and not necessarily on the problems and the crises that the particular populations are facing. It’s important to spend more time engaging, researching, understanding the program that you want to solve, than trying to solve the problem itself.”
Maswime stressed the importance of thoroughly researching and understanding the problem before attempting to solve it, as poorly designed interventions can create new problems.
“Success is not about the intervention itself but whether the beneficiaries are better off than before we came,” she said.
