Cross-Sectional Study
A national roadmap for improving children surgical care: an experience from Tanzania Godfrey Sama Philipo, MD, MPH, MGSCa,b,*, Zaitun M Bokhary, MD, MMed, FCS (PAED)a,c, Kokila Lakhoo, PhD, FRCS, FCS (SA), FCS (PAED), MRCPCH(UK), MBCHBa,d,e Purpose: Nearly 1.75 billion children lack access to basic surgical care. The majority are in low- and middle-income countries (LMICs) where 50% of the population are children. Our aim was to develop a policy-level, action-orientated, and implementable strategy to improve children surgery in Tanzania. Methods: A bottom-up participatory approach was used for needs assessment and priority setting. This started 2 years after the launch of Tanzania National Surgical, Obstetrics, and Anesthesia Plans (NSOAPs). Steps taken were: (i) stakeholder identification and engagement, (ii) desk review of existing research, (iii) focused research on access to children surgery, (iv) site visits and geographical mapping of the reach of selected hospitals, and (v) presentation to the ministry of health for validation. Findings were summarized in line with the NSOAP’s building blocks. Results: A bottom-up approach was feasible in identifying children surgical care challenges of policy priority. We noted that regional hospitals are the main provider of children surgery but majority lacked the necessary resources and were beyond recommended 2-hour reach. A super hub–hub–spoke model is a feasible model to pragmatically address patient, provider, facility and national challenges at all levels of healthcare system. Conclusion: Our findings propose a roadmap to practically achieve access to children surgery, complementing existing NSOAPs. It highlights feasibility of the approach in developing context relevant interventions that could guide integration of surgery in existing national plans. Developing a functional surgical system in LMICs should be pragmatic to improve overall quality of children surgical care despite limited resources. Keywords: children surgery, implementation science, low- and middle-income country, national plan, super hub–hub–spoke
Introduction
HIGHLIGHTS
The Lancet Commission on Global Surgery estimated that 5 billion people worldwide lack access to basic surgical care[1]. An estimated 90% are in sub-Saharan Africa (SSA) and nearly 1.8 billion are children[1,2]. In many SSA countries, children comprise over 50% of the total population[2,3]. Approximately 85% of children in lowand middle-income countries (LMICs) will have a surgically-treatable condition by the age of 15 years[4]. Pediatric surgical conditions often lead to lifelong disability or death, as they arise during critical developmental years[5]. However, less than 8% of children in these countries have access to even the basic surgical care services[2,6-9]. Access to surgical care for children remains poor and
Many countries are progressing at different stages of NSOAP implementation, but children-specific interventions remain limited, despite children comprising over 50% of the population ● A bottom-up approach is both feasible and effective for the designing, implementation and uptake of NSOAPs. ● A child-focused surgical improvement roadmap should be pragmatic – striving for the highest attainable standards while prioritizing quality at every stage and level of surgical care system ● The super hub–hub–spoke model offers a structured framework to support effective implementation and improvement of children surgical outcomes at all levels of care. ●
a
Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania, University of British Columbia, Branch of Global Surgical Care (BGSC), Vancouver, Canada, cMuhimbili National Hospital, Dar Es Salaam, Tanzania, dUniversity of Oxford Global Surgery Group (OUGSG), Oxford UK and eNuffield Department of Surgical Sciences, University of Oxford, UK
b
*Corresponding author. Address: Muhimbili University of Health and Allied Sciences (MUHAS), Dar Es Salaam 65001, Tanzania. Tel.: +255 766925812. E-mail: godfreysama2@yahoo.com (G. S. Philipo). Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons AttributionNon Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. International Journal of Surgery (2025) 111:5002–5011 Received 27 February 2025; Accepted 24 May 2025 Published online 24 June 2025 http://dx.doi.org/10.1097/JS9.0000000000002629
often overlooked in national health priorities[1,10]. Additionally, surgical service delivery is fragmented, with inadequate infrastructures, workforce and financing[1,10-12]. As previously evidenced, a pediatric surgery workforce density of less than 0.37 per 100 000 is linked to decreased survival rates[13]. Some of the SSA countries have as low as 0.03 children surgical workforce per 100 000 children population under 15 years, resulting into poor outcomes of conditions amenable by surgical care[14-16]. In March, 2018, Tanzania launched its 5-year National Surgical, Obstetrics, and Anesthesia Plans (NSOAPs), highlighting the government’s commitment to enhancing surgical care[17,18]. Inadequate data, limited funding, and lack of childspecific strategies are key barriers to effectively addressing
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children’s surgical needs through NSOAP implementation[19]. Additionally, most policy development and implementation processes tend to follow a top-down approach, with limited engagement from frontline stakeholders. Shortage of pediatrics surgical providers may further result in insufficient input for designing comprehensive children surgical services. This leads to a lack of ownership within the professional community and a limited understanding of the implementation process[20]. As Dr. Tedros, the Director-General of WHO, stated, “The world is full of frameworks, roadmaps, and action plans that sit on shelves collecting dust and never make a difference to people. I urge you, starting now, to translate your good intentions into concrete actions that transform the health of your people.” Our goal was therefore to adopt a bottom-up approach to develop and propose a feasible roadmap for children’s surgery stakeholders in Tanzania and beyond, aimed at enhancing pediatric surgical care tailored to local contexts.
Process of developing the national roadmap A participatory approach for needs assessment, situational analysis, and interventions design informed to develop this roadmap. The process started in 2020, 2 years after the launch of the Tanzania NSOAP. We formed a Technical Working Group that comprised of a Tanzanian (a children surgery researcher and pediatric surgeon), two MOH officials, and one external partner. For over 20 years, these partners have worked toward improving children surgery in Tanzania through research, workforce development, capacity and mentorship, infrastructure improvement, systems strengthening, and care delivery[21]. To obtain local knowledge, we undertook the following steps: 1) Stakeholder identification and engagement Key stakeholders identified and engaged were (1) policy and decision makers (Ministry of Health – MOH, hospital directors), (2) service providers (pediatric surgery providers and researchers), (3) parents and caregivers to represent children voices, (4) educators and trainers from universities and/or colleges, (5) funders, and (6) media. Our first stakeholder engagement meeting was held in 2020 and served as a high-level forum to explore existing challenges, interests, opportunities, and priority areas for improving children surgical care. Participants shared their experiences and identified the need to scale up surgical services for children beyond tertiary national and regional hospital. Areas for potential collaboration with local and external stakeholders working in Tanzania were identified. This was followed by a series of in-person and virtual engagements. 2) Situation analysis through desk review and focused research We began by reviewing Tanzania’s NSOAP, the Health Sector Strategic Plan (HSSP V), and regional documents, followed by research studies aimed at understanding the current state of pediatric surgical care in the country[12,17,18,22-24]. These studies were conducted at the tertiary hospital, based on the hypothesis that pediatric surgical care is primarily concentrated at this level, offering valuable insight into the broader realities in the country. We obtained data form patient interviews as well as reviewing surgery
records at MNH. There are limited system-level studies done to assess the progress of NSOAP implementation in Tanzania. 3) Site visits of and geographical mapping of selected regional hospitals In 2022, we conducted site visits to get contextual information on barriers, facilitators, and priorities for pediatric surgical care in respective hospitals. Hospitals visited were selected to ensure representation of all the 6 zones of Tanzania (Eastern, Northern, Lake, Western, Central, South West Highlands, Southern Highlands, Southern and Zanzibar Zone). During these visits, we continued engaging with key stakeholders (hospital directors, surgery departments heads and children’s surgical providers) and conducted observational tours of hospitals. Lastly, we conducted geographic mapping to better understand the reach of these hospitals and the catchment areas they serve. We used Quantum Geographic Information System (QGIS) mapping software with the Open Route Service (ORS) plugin. Data from OpenStreetMap, an open-source geospatial database containing road networks and geographic features, were used to generate isochrones. These were manually configured to illustrate the areas from which individuals could access each hospital within a 2-hour driving distance. This time has been shown to be associate with better outcomes for patients requiring emergency surgery[1]. 4) Hospital survey and making an investment case We conducted a cross-sectional survey at selected regional hospitals using to gather detailed information, complementing data obtained from previous processes. This aimed at gaining more insights into the value and feasibility of investment by government or other organizations. The scope of the survey included understanding hospital catchment areas, workforce density, surgical volume, and infrastructure readiness for the development of children surgical services. At this stage, we also engaged Kids Operating Room (Kids OR), a global health charity that supports the transformation of children’s surgical care worldwide by investing in local capacities[25]. 5) Validation meetings and adoption of the roadmap In-person or virtual validation meeting were conducted with various MOH leaders directly or indirectly involved in healthcare systems planning and implementation. This included the Director for Curative Services, NSOAP Lead, and Director noncommunicable diseases (NCDs). A tentative plan of how and where children surgery could develop was presented to MOH for more inputs and validation to ensure that it is in line with the policy priorities and existing plans within the MOH to improve children’s health. We have used the Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery (STROCSS) criteria to report the information in this study[26].
Result Stakeholders’ engagement We engaged participants from 16 regional referral hospitals, 1 tertiary and national hospital, 3 private hospitals, 2 Tanzania’s
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major medical universities and 1 college of surgeons (Table 1). There was urgency commitment, motivation and support to developing an operational roadmap, reaching both urban and rural settings. To ensure a comprehensive and operational roadmap, participants emphasized the need to scale up of surgical services for children beyond tertiary and regional hospitals. The bottom-up approach proved to be feasible, cost-effective, and acceptable in identifying challenges and informing the designing of strategies to improve children surgical. It included voices of children’s surgery providers – most of whom are key implementers but are often excluded in traditional policy-making processes. They reported a sense of ownership and relevance of the proposed strategies. Situation of children surgery in Tanzania In Tanzania, 17% of disease burden was identified as amenable to surgical treatment, 19.3% of deaths were attributed to diseases that could be addressed surgically and 65.8% of people were at risk of catastrophic expenditure due to surgery[17]. Inadequate workforce, limited infrastructure, insufficient financing, poor research output, suboptimal patient outcomes, complicated referral systems, and limited local and international collaborations were key and common challenges. Hospitals in Tanzania are at varying stages of development in their capacity to provide children surgical services. Pediatric surgery care available in 2 hospitals, with training both as a Master’s of Science Degree at MUHAS and COSECSA Fellowship (FCS) at MNH and BMC. Tanzania has adopted a training curriculum for nonpediatric surgery providers from India[27]. It emphasizes (i) fostering effective teamwork, (ii) ensuring appropriate management of both routine and emergency pediatric surgical cases, (iii) trauma management, (iv) triage and safe transfer of complex cases, and (v) enhancing communication between tertiary centers and regional/district general hospital[27]. A total of 54 Tanzania’s adult surgical providers from 10 regional hospitals have been trained. Tanzania (MNH – Dar Es Salaam) team has become a super hub for Africa, disseminating this training to other countries, such as Botswana, Ethiopia, Ghana, Kenya, and Zambia, to independently lead this course in their respective countries. We have summarized the current situation and challenges in the table below (Table 2).
The annual surgical volume at a tertiary hospital for children’s surgery was approximately 1120 general surgeries, covering various conditions (Table 3), along with 900 neurosurgery and 300 orthopedic surgeries. Most of these conditions require early diagnosis, referral, and complex surgeries, leading to long hospital stays. At BMC, general pediatric surgery ranged from 700 to 1000 cases per year, pediatric neurosurgery accounted Table 2 Challenges facing children surgery in Tanzania Workforce shortage: Few pediatric surgical care providers (surgeons, theatre nurses, pediatric anesthesiologists, biomedical engineers) As of 2024, there are 15 general pediatric surgeons 11 pediatric neurosurgeons, 7 pediatric orthopedic surgeons and 4 pediatric urology in the country, making a total of 37 pediatric surgeons Anesthesiologists were 85 with only 3 pediatric anesthesiologist Two nurses trained in perioperative nursing care all at MNH The role of other providers, apart from surgeons, is not fully highlighted Limited training opportunities on children surgery (MUHAS and MNH) Lack of countrywide refresher courses for providers in regional hospitals, districts hospitals Children surgical services delivery: Long distances to access surgical care, majority of patients taking longer than 2 hours High costs associated with seeking and receiving children surgical care Inaccessibility of some regional hospitals such as Rukwa, Mtwara, and Ruvuma with no reliable support despite the existing need Ineffective and complicated referral patterns as well as delayed referrals Long waiting time and backlog due to limited infrastructure and workforce Poor post-operative outcomes, with high complication and mortality rates Lack of defined level of care provided at various levels of hospitals and when to refer Children surgery research: Limited research training and mentorship Limited research funding and limited knowledge on grants application Difficulty in balancing research time with clinical work, prioritizing patients/clinical care Lack of support for children surgery research support to audit their practice Most collaborations focus on clinical care with minimal emphasis on research. Lack of collaboration between researchers and clinicians and hence difficulty in translation of the research finding. Absence of research infrastructure and essential facilities and research databases Pediatric professional association:
Table 1 Stakeholders analysis according to their power and influence
Poor communication among children surgery providers in the country, limiting opportunities for mutual learning and local collaboration
Stakeholder
Power
Influence
Limited advocacy activities on children surgery improvement
Policy makers Hospital directors/managers Funders Program managers Medical doctors, general surgeons, and pediatric surgeons Anesthesiologists Nurses (perioperative nurses and ward nurses) Academics and researchers Children’s surgery champions Parents and guardians of surgical patients Collaborators Medical universities and colleges (MUHAS, KCMUCo, COSECSA) Private hospitals
High High High High Medium
High High High Medium High
Children surgery infrastructure:
Medium Medium Medium Medium Low Low Specialized
High Medium Medium Medium Medium Medium Specialized
Policy priorities for children surgery:
Specialized Specialized
Insufficient number of pediatric operating theaters Limited access for children due to sharing with adult surgery Poorly developed theatres
Inadequate financing of the overall NSOAP Lack of research funding for research and care Limited stakeholders and funders specific for children surgery Lack of focus on surgery and its role in improving the overall health system Limited implementation of existing strategies in line with other health plans. Poor access to training due to lack of simulation centers especially in southern region to provide access to continued learning, practicing and perfecting their skills.
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Table 3 The top ten surgical conditions among children at MNH Condition Anorectal malformation Hirschsprung disease Hernias (inguinal or scrotal) Hypospadias Umbilical or epigastric hernia Wilms tumor (nephroblastoma) Conditions requiring circumcision (e.g., phimosis, redundant prepuce) Posterior urethral valve Burn contractures Burns
N (%) 424 (12.6) 292 (8.7) 220 (6.5) 174(5.2) 145 (4.3) 102 (3.0) 92 (2.7) 90 (2.7) 84 (2.5) 76 (2.3)
for 180, pediatric orthopedic surgery was 165 case, and Urology pediatric surgery was 36 cases annually. The lack of research activities in most hospitals was due to limited funding, insufficient research expertise, and a heavy surgical patients load requiring urgent attention. Regional hospitals had inadequate capacity to provide surgical care with nearly 76% of children being referred to the tertiary/national hospital[12]. The main reasons for referrals were limited infrastructure and a lack of pediatric surgery expertise. Hence patients travel long distances and incur higher costs than if they had received care locally in regional hospitals[12,22]. Additionally, nearly 21% of children referred to tertiary level had conditions that could have been treated at regional hospitals (e.g., hernias, appendicitis, and lipoma). This places an unnecessary burden placed on tertiarylevel hospital, potentially limiting surgical care provision (Fig. 1). Geographical mapping revealed that very few people were within a 2-hour reach of the selected hospitals. This may be
attributed to infrastructural challenges beyond the health system, such as inadequate road networks and transportation. Lowerlevel facilities, such as districts and health centers, typically staffed by non-specialists and non-surgeons, are the most affected and continue to have limited access to children surgical care (Fig. 2). The review of Tanzania’s NSOAP revealed that Strategic Objective 3.1 (Activity 1.9) sets a target of training 15 pediatric surgeons and 240 anesthesiologists by 2025, with an estimated budget of USD 1 538 805. The plan also recommends establishing designated satellite training centers at fully functional surgical or zonal hospitals in each zone, adopting a collegiate training model to strengthen decentralized capacity-building and mentorship. The NSOAP also called for the MOH to review staffing levels to include surgery and anesthesia specialists in the MOH’s minimum staffing guidelines down to the district level. There were interests to improve children surgery at a regional level through the East, Central and Southern Africa Health Community (ECSA HC). Resolutions of the 71st ECSA HC Health Ministers Conference in 2023 urged member states to Strengthen and/or build comprehensive, sustainable pediatric surgery and anesthesia programs, to address the gaps and high burden of pediatric surgical disease. It also called for increased investment in pediatrics surgical services including supporting the establishment of Centers of Excellence (CoE) for pediatric surgery.
Implementation strategies to improve children surgery Our proposed roadmap for a nationwide improvement of children surgery should ensure the following: 1) Service delivery
Figure 1. (a) Referring health facilities and (b) main reasons for referral of children seeking surgical care at MNH[12].
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Figure 2. Mapping of 2-hour reach to the 10 selected centers potential to develop children surgery. The colors as shown in the key within selected regions show areas that are able to reach a hospital (white star). Regions are colored based on the population density from white to deep gray.
Adopt super hub–hub–spoke model as a potential strategy to improve nationwide access to children surgery, bringing care closer to people. Super hub can be a tertiary hospital and should support the development of hubs (regional hospitals). Both super hub and selected hubs should be developed to children surgery CoEs. CoEs are designed to significantly enhance the depth and breadth of healthcare services through the delivery of quality surgical care, research and innovation, training and mentorship, leadership and governance, and advocacy for children’s surgery[28]. Furthermore, hubs will extend their support to spokes – district hospital and health centers – to ensure a cohesive and effective surgical network. Each spoke should have a trained pediatric surgery champion to manage minor pediatric surgical conditions, and ensure timely triage and referral to the hubs or super hubs (Table 4). These developments are sequential, aiming for the best care possible as per international standards while recognizing the need for ongoing efforts at every level, and ensure improved care throughout the implementation process (Fig. 3). Hence, this model could guide priority-setting across the country and ensure a robust pediatric surgery system, with improved outcomes across the country. As for Tanzania, the super hub is MNH in Dar Es Salaam, while 10 regional hospitals in Arusha, Dodoma, Iringa, Kilimanjaro, Kigoma, Lindi, Mwanza, Mbeya, Mtwara, Rukwa, and Zanzibar are potential hubs.
2) Children Surgery Workforce Development International standards recommend 1 qualified pediatric surgeons and 5 anesthesia providers per 100 000 patients between 0 and 15 years of ages[29,30]. Given the 62 million population of Tanzania, we suggest a phased approach aiming for 1 pediatric surgeon and 1 pediatric anesthesiologists per 1 million and 5 million populations respectively in the next 5 years. This is 62 pediatric surgeons and 13 pediatric anesthesiologists (in addition to 240 general anesthesiologists as proposed in the current NSOAP) distributed in the super hub and hubs. Additionally, 12 biomedical engineer (1 in every hub, 2 in super hub) and 100 perioperative nurses (10 at super hub and 7 at every hub) for children surgery infrastructure. Lastly, while the development of specialized care providers continues, capacity building for non-pediatric surgery providers should also be sustained. On-job training on children surgery to be implemented to 500 adult surgical team in Tanzania. 3) Infrastructure Development In Tanzania, 3 fully fledged super hub and 10 regional hospitals developed as hubs with the necessary infrastructure (theatres, wards, and other equipment) to provide children surgery as a starting point. This will reduce sharing of theatre space with
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Table 4 The roles of functions of super hub, hubs, and spokes and other implementing bodies in improving children surgical care Super hub – MNH: Lead specialized training of children surgical providers (pediatric surgeons, anesthesiologists, perioperative nurses) Facilitate discussions with potential funders for creating children operation theatres and scholarship support for trainees To lead the training in the spokes by visiting spokes or hosting providers for training Leading the implementation t of the children surgical plan (situational analysis, strategy, and drafting the final draft) Come up with implementation and evaluation plan of the program Continue with grant applications and identification of potential international partner to support these development financially Formation of a research agenda Ministry of health – two members:
needs. This can be achieved by participating in global observance days for children or by adopting specific national days, such as Gastroschisis Day in Tanzania[31]. These initiatives offer an opportunity to engage a broader range of stakeholders while demonstrating that our efforts are aligned with existing global, regional, or national initiatives and calls to action. Additionally, forming and actively involving pediatric surgery associations – and ensuring their participation in policy dialogues at the national, regional, and global levels – is fundamental. The invaluable role of patients should also be recognized and highlighted. While learning from the experience of others is valuable, it is even more critical to have a seat at the decision-making table. Advocacy for children’s surgery should adopt a multifaceted approach to: increase investment, enhance local capacity, establish local and international partnerships, and promote community awareness. 5) Financing and Governance
To continue supporting the development of this plan giving strategic directions at policy level in line with other health plans Support training at various levels from hub and spoke to specialized training in areas where hubs are being developed. Currently the program is not yet funded Support the development of the plan To review the draft of plan, launch and own it to guide children surgical care development at country level Ministry of Health is willing to support the training in India The NSOAP advised the increase in number and quality of research projects The need for research prioritization in the National Research Medical Research Institute Hubs (10 identified regional hospitals): Have a children surgery champion to spearhead these developments Facilitate the hub and spoke model using internal resources for capacity building Support in the situational analysis with the leading team and filling the kids OR hospital assessment forms Work with the leading team to identify potential candidates Work with the team and ministry of Health to come up with a feasible dates/timelines for training Each hub should contain a pediatric team that include a surgeon, ward nurses, theatre nurse, anesthetist, intensivist/orthopedic surgeon etc. and researchers Provide supportive supervision to the districts and health centers Spoke (district and health centers): Having children surgery champions in districts and health centers Improving triage and referral networks Integrating into various programs, e.g., maternal care
adult patients, increasing children surgical volumes and workforce. An experience from developing children theatres at MNH and BMC provided Fellowship and MSc Pediatric Surgery training opportunities through the college (COSECSA) and university (MUHAS) respectively. Stakeholders emphasized the need to develop and utilize simulation centers to expand access to training – particularly in remote areas – while optimizing the existing trainer workforce. 4) Advocacy for Children Surgery A robust advocacy framework should be in place to ensure continuous engagement of stakeholders. Effective advocacy is essential for securing buy-in and influencing policy, but it requires significant time and collective effort, supported by robust, high-quality data and science that address recognized
It is important to continue exploring existing funding available to hospitals, which can support improvement of children surgical care. This roadmap highlights priority areas and identifies opportunities for engaging diverse stakeholders. It also outlines potential synergies and how children surgery can be integrated into existing national plans. Collaboration with external institutions and NGOs should continue to support the improvement of children surgery, with sustainability in mind and ultimate goal of supporting countries achieve self-reliance. External funding is only a means to catalyze and demonstrate the initial feasibility of children surgery development. However, sustainable solutions depend on the commitment of local funding from the MOH and local stakeholders. Additionally, we noted the need for strengthening health insurance coverage to alleviate costs incurred by patients. More than 70% of babies needing emergency surgical care did not have any health insurance[12]. 6) Information Management and Research For this roadmap, we propose the formation of a National Children Surgery Research Program and the establishment of research databases. This initiative will ensure a learning surgical system that continuously collect data for quality improvement and priority setting to enhance children surgery. It will also drive research capacity-building programs for multidisciplinary teams and support the delivery of robust research studies. This approach has previously shown to be feasible through a partnership program between MNH and the University of Oxford[21]. The program has led to evidence generation that has informed formation of this roadmap[12,23,31,32]. A number of projects in capacity building and mentorship programs are currently ongoing and benefiting surgical teams. We also developed and piloted the feasibility of using a REDCap database in multicenter data collection, now operating in 12 regional hospitals[31]. This provides a potential to expanding these efforts to all hubs and incorporate of children surgical data into the national DHSI-2. We have developed a tentative evaluation Logical Framework of development of Children Surgery addressing the areas of the building blocks of health system (Fig. 4). However, this should be contextualized allowing each hub to have Key Performance Indicators for effective implementation of the national strategy.
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Figure 3. Showing an implementation of super hub–hub–spoke strategy and its implementation. Selected centers as super hub (green cycle) and hubs (blue triangles), and how the hubs link and relate with the spokes (red stars).
Discussion and conclusion This program proposed a pragmatic approach increased number of specialists and non-specialists, expand children surgical services and training, improve referral systems, strengthen children surgical information management, research and evidence generation, and incorporation of children surgery in the NSOAP
and other MOH plans. It also proposes measures to improve financing and reduced financial burden in children surgical care using a feasible nationwide strategy. We highlight the adoption of bottom-up approach development of policy documents for better uptake and buy-in from key stakeholders. The approach allowed for a comprehensive planning process, engaging key stakeholders for children surgery, to generate evidences that
Figure 4. Logical framework of development and evaluation of children surgery.
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are reliable to develop a children surgery roadmap. It can be an important tool to continue advocating for children surgery development in Tanzania and beyond. An implementation, monitoring and evaluation tool is also suggested to be incorporated in the NSOAPs or overall MOH plan. In this document, we align and address the 6 Building Blocks of healthcare and suggest the “how to do and the who to engage” in order to attain the intended goals. Tanzania and Africa is still lagging behind in achieving safe surgery and up taking of the WHO World Health Assembly Resolutions[19,33-35]. Many countries have not achieved the goals of having NSOAPs even those that have or are currently renewing theirs for another phase of implementation[20,36]. Persisting gaps in the provision of pediatric surgery highlights the ongoing challenges in meeting the surgical needs of children across the country. Understating these challenges is the first step and it needs local knowledge from all key stakeholders. Evidence already shows the gaps in effective engagement in the development which will eventually affect the implementation process. A study done in 2023 reviewing 8 NSOAPs in SSA, only 25% had dedicated sections to children’s surgery, 12.5% acknowledged engagement with children’s surgical care professional societies, and 50% acknowledged the roles of children’s surgical care providers in the development of the policy[37]. Children are not simply “small adults”; they have unique surgical needs. Without intentional integration of children’s surgical care into broader surgical health system strengthening strategies, there is a high risk that children will lack access to appropriate care when and where it is needed. We highlight a bottom-up approach to policy planning and implementation as an effective evidence-based strategy. This approach leverages six key attributes that facilitate healthcare change: (1) influence, (2) ownership, (3) physical presence at the point of change, (4) grit, (5) persuasiveness, and (6) participative leadership style[38]. It has proven effective in guiding prioritization, funding allocation, and decisions-making through investment cases and use of recommended models for surgical health financing[39]. Effective interventions for policy uptake and implementation are context-specific and may work in one setting but fail in another, even within the same country[40]. Hence, without the support of clinicians and other key stakeholders, policy interventions are at risk of failure. We clarify areas where all stakeholders, external and local, working at various levels of healthcare will understand what is expected of them in this roadmap. Although this approach was feasible and effective, we emphasize a mixed approach as both top-down (from policy makers, administrators) and bottom-up (support for and from healthcare providers) provide important perspectives required for effective design and implementation of national strategies. There is a need to develop an evidence-informed advocacy strategy with clearly defined priorities, roles and responsibility that reach more stakeholders. The impact of this has already been shown in the implementation of Nigeria NSOAP[41]. We noted the higher need for children surgical care, mainly in the rural settings of Tanzania[42]. Scaling up surgical care requires sequential, stagewise planning – prioritizing centers that can reach the most people and provide the best care as we aim for international standards[29,30,43]. A super hub–hub–spoke model have a potential of ensuring surgical care is available at every level or timely referral. Emerging evidence demonstrates
that major surgery can be performed safely and effectively at all level of healthcare[6]. This underscores the importance of a proper and timely referral system to ensure access for often neglected rural populations. On geographical mapping, few people were able to reach the selected hospitals (hubs) within 2 hours. Addressing factors such as poor road infrastructure in rural areas, ineffective transportation, and health-seeking behaviors – such as a preference for traditional medicine – is crucial, as these can compound existing health-related barriers. Ensuring the availability of surgical care at first-level hospitals in LMICs could avert approximately 22% of the 1.4 million annual deaths among children and adolescents[8]. We are already seeing its feasibility and impact of our strategy. There are ongoing trainings at both specialist and on-the-job, with support from the government, grants and Charity organizations. Various initiatives including decentralization of Gastroschisis care, a neonatal surgery bellwether procedure, has now reached more than 15 hospitals in Tanzania, improving outcomes of these babies[31,44,45]. With various funding we are also developing Children Surgery Research Office and continue to collaborate in generating local data for policy making. We have provided Technical Support to Uganda and Botswana in developing their children surgery national strategies. Our limitations include, firstly, the lengthy development process, primarily due to a lack of dedicated funding. However, this also provided an opportunity to follow up on the implementation of Tanzania’s NSOAP and assess its integration with children’s surgery, helping us to design a more appropriate plan. The extended timeline enabled broader engagement with a wide range of stakeholders, whenever an opportunity raised, and a deeper understanding of variations within the country. Secondly, some voices may have not been represented fully as we engaged only those available in the country. For example, perioperative nurses, biomedical engineers, and pediatric anesthesiologists are either very few or absent, limiting direct insight into the needs at hub facilities. To address this gap, we incorporated information from available literature from similar contexts. Thirdly, our engagement did not include ministries beyond the MOH. Policy documents such as this should actively seek, and would be enriched by, the involvement of other ministries, for example, the Ministries of Finance and Infrastructure. It was also important to engage the WHO Tanzania Country Office, UNICEF and other agencies responsible for improving children health. We acknowledge this gap and recommend their involvement during the NSOAP review and renewal in 2025. In conclusion, as Tanzania’s NSOAP approaches its review and renewal in 2025, existing evaluations have already highlighted various gaps in implementation[20]. Like in many other countries, the plan has thus fallen short of achieving its intended outcomes. This children’s surgery plan is timely and well-positioned to inform priority areas, offering a replicable approach for similar contexts. It contributes valuable evidence that can guide Ministries of Health in ensuring children’s surgical care is prioritized in the next NSOAP cycle. Ultimately, effective policy planning and implementation depends on the meaningful identification and engagement of stakeholders. With continued policy support and coordinated efforts, Tanzania is well placed to sustainably expand access to surgical care for all its population.
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Ethical approval This manuscript did not require an IRB. The Ministry of Health of Tanzania provided the approval letter.
Consent No consent form was needed as information on patient data are either hospital information or from previous publications.
Sources of funding Children Research Fund (CRF) and Kids Operating Room (Kids OR).
Author contributions G.S.P. and K.L.: conceptualization of the study, data collection, analysis, interpretation and writing of the manuscript; Z.M.B.: conceptualization of the study, review and approval of the final manuscript.
Conflicts of interest disclosure The authors declare no conflicts of interest for this work.
Research registration unique identifying number (UIN) Not applicable.
Guarantor Dr Godfrey Sama Philipo.
Provenance and peer review Not commissioned, externally peer-reviewed.
Data availability statement Data are available upon reasonable request.
Acknowledgements The authors thank Ministry of Health of Tanzania and Kids OR.
References [1] Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569–624. [2] Mullapudi B, Grabski D, Ameh E, et al. Estimates of number of children and adolescents without access to surgical care. Bull World Health Organ 2019;97:254–58. [3] Population Reference Bureau [Internet]. cited [2023 Aug 2]. PRB’s 2022 World Population Data Sheet. Available from: https://2022-wpds.prb.org/ [4] Bickler SW, Rode H. Surgical services for children in developing countries. Bull World Health Organ 2002;80:829–35.
[5] Ozgediz D, Poenaru D. The burden of pediatric surgical conditions in low and middle income countries: a call to action. J Pediatr Surg 2012;47:2305–11. [6] Grabski D, Ameh E, Ozgediz D, et al. Optimal resources for children’ s surgical care: executive summary. World J Surg 2019;43:978–80. [7] Ozgediz D, Langer M, Kisa P, Surg M. Pediatric surgery as an essential component of global child health. Semin Pediatr Surg 2016;25:3–9. [8] Sykes AG, Seyi-Olajide J, Ameh EA, et al. Estimates of treatable deaths within the first 20 years of life from scaling up surgical care at first-level hospitals in low- and middle-income Countries. World J Surg 2022;46:2114–22. [9] Advocating for the inclusion of children in global surgery: the global initiative for children’s surgery (GICS) model | East and Central African Journal of Surgery [Internet]. cited [2021 Jan 31]. Available from: http:// journal.cosecsa.org/index.php/ECAJS/article/view/20190037/1511 [10] Shrime MG, Dare AJ, Alkire BC, O’Neill K, Meara JG. Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health 2015;3:S38–44. [11] Bedwell GJ, Dias P, Hahnle L, et al. Barriers to quality perioperative care delivery in low- and middle-income countries: a qualitative rapid appraisal study. Anesth Analg 2022;135:1217. [12] Philipo GS, Bokhary ZM, Bayyo NL, et al. A journey undertaken by families to access general surgical care for their children at Muhimbili National Hospital, Tanzania; prospective observational Cohort Study. World J Surg 2022;46:1643–59. [13] Bouchard ME, Tian Y, Justiniano J, et al. A critical threshold for global pediatric surgical workforce density. Pediatr Surg Int 2021;37:1303–09. [14] Krishnaswami S, Nwomeh BC, Ameh EA. The pediatric surgery workforce in low- and middle-income countries: problems and priorities. Semin Pediatr Surg 2016;25:32–42. [15] Bustorff-Silva J, Miranda ML, Rosendo A, Gerk A, Oliveira-Filho AG. Evaluation of the regional distribution of the pediatric surgery workforce and surgical load in Brazil. World J Paediatr Surg 2023;6:e000522. [16] Hamad D, Yousef Y, Caminsky NG, et al. Defining the critical pediatric surgical workforce density for improving surgical outcomes: a global study. J Pediatr Surg 2020;55:493–512. [17] National Surgical, Obstetric and anaesthesia plan (nsoap)2018 – 2025. The United Republic of Tanzaniaministry of Health, Community Development, Gender, Elderly and Children; 2018. Available from: https://static1.squarespace.com/static/56b8ed53b6aa60903fe8e7f5/t/ 5e578792fe7516041e38d68b/1582794655754/3_Tanzania+NSOAP. pdf [18] Tanzania. Ministry of Health, Community Development, Gender, Elderly and Children [Internet]. Health Sector Strategic Plan IV; 2015. //www.prb.org/wp-content/uploads/2020/06/Tanzania-Health-SectorStrategic-Plan-IV-2015-2020-1-4.pdf [19] Peters AW, Roa L, Rwamasirabo E, et al. National surgical, obstetric, and anesthesia plans supporting the vision of universal health coverage. Glob Health Sci Pract 2020;8:1–9. [20] Hellar AM, Akoko L, Jumbam DT, et al. An assessment of progress and challenges in the implementation of the National Surgical, Obstetric, and Anesthesia Plan (NSOAP) in Tanzania. East Central Afr J Surg 2024;29: 15–22. [21] Philipo GS, Nagraj S, Bokhary ZM, Lakhoo K. Lessons from developing, implementing and sustaining a participatory partnership for children’s surgical care in Tanzania. BMJ Glob Health 2020;5: e002118. [22] Philipo GS Out of pocket and catastrophic health expenditures of families from seeking pediatric surgical care in a tertiary hospital in Tanzania [Internet]. 2023 cited [2023 Jun 2]. Available from: https:// open.library.ubc.ca/soa/cIRcle/collections/graduateresearch/42591/ items/1.0431428 [23] Philipo GS, Bokhary ZM, Bayyo N, et al. A randomised control trial using soap in the prevention of surgical site infection in Tanzania. J Pediatr Surg 2022. [24] Klazura G, Park P, Yap A, et al. Pediatric surgical waitlist in low middle income countries during the COVID-19 pandemic. J Surg Res 2023; 288:193–201. [25] Cunningham D, Fedatto M. Building towards equitable access to safe surgery for every child. J Pediatr Surg 2022;57:182–86.
5010
Philipo et al. International Journal of Surgery (2025)
[26] Agha R, Mathew G, Rashid R, et al. Updated reporting guidelines in the age of artificial intelligence: SCARE, PROCESS, STROCSS and TITAN 2025. Prem J Sci 2025;10:100081. [27] Madhuri V, Stewart RJ, Lakhoo K. Training of children’s surgical teams at district level in low- and middle-income countries (LMIC): from concept to reality—a south to south initiative. Int J Surg Glob Health 2019;2:e08. [28] Elrod JK, Fortenberry JL. Centers of excellence in healthcare institutions: what they are and how to assemble them. BMC Health Serv Res 2017;17:425. [29] O’Neill JA, Cnaan A, Altman RP, et al. Update on the analysis of the need for pediatric surgeons in the United States. J Pediatr Surg 1995;30:204–10. [30] Gelb AW, Morriss WW, Johnson W, et al. World Health OrganizationWorld Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesth Analg 2018;126:2047–55. [31] Philipo GS, Bokhary ZM, Kapapa M, et al. Improving care and survival of newborns with surgical conditions in Tanzania (TINY Tanzania): a focus on gastroschisis. Pediatr Surg Int 2024;40:250. [32] Pilkington M, Brindle M, Philipo GS. Creation of an enhanced recovery after surgery protocol for children with Wilms tumours in low- and middle-income countries. J Pediatr Surg Open 2023;4:100070. [33] Truché P, Shoman H, Reddy CL, et al. Globalization of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery. Glob Health 2020;16:1. [34] Reddy CL, Makasa EM, Biccard B, et al. Surgery as a component of universal healthcare: where is South Africa? SAMJ South Afr Med J 2019;109:624–25. [35] Integrated emergency, critical and operative care (ECO) [Internet]. cited [2024 Aug 21]. Available from: https://www.who.int/teams/integratedhealth-services/clinical-services-and-systems/emergency–critical-andoperative-care
[36] Bekele A, Alayande BT, Powell BL, et al. National surgical healthcare policy development and implementation: where do we stand in Africa? World J Surg 2023;47:3020–29. [37] Hyman GY, Obayagbona KI, Mugwe R, Makasa EM. The need for children’s surgical care prioritisation in national surgical care policies: a systematic review of National Surgical Obstetric and Anaesthetic Plans (NSOAPs) in Sub-Saharan Africa. J Pediatr Surg 2024;59: 299–304. [38] Bonawitz K, Wetmore M, Heisler M, et al. Champions in context: which attributes matter for change efforts in healthcare? Implement Sci 2020;15:62. [39] Jumbam DT, Reddy CL, Meara JG, Makasa EM, Atun R. A financing strategy to expand surgical health care. Glob Health Sci Pract 2023;11: e2100295. [40] Chambers JD, Salem MN, D’Cruz BN, Subedi P, Kamal-Bahl SJ, Neumann PJ. A review of empirical analyses of disinvestment initiatives. Value Health 2017;20:909–18. [41] Seyi-Olajide JO, Faboya O, Williams O, Lakhoo K, Ameh EA. Advocating for children’s surgery within country health plans: lessons from Nigeria and the global stage. Front Public Health 2023;11:1209902. [42] Butler EK, Tran TM, Nagarajan N, et al. Epidemiology of pediatric surgical needs in low-income countries. PLOS ONE 2017;12:e0170968. [43] Parigi G, Czauderna P, Rolle U, Zachariou Z. European census on pediatric surgery. Eur J Pediatr Surg 2018;28:227–37. [44] Wright N, Abantanga F, Amoah M, et al. Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings. Wellcome Open Res 2019;4:46. [45] Ford K, Poenaru D, Moulot O, et al. Gastroschisis: bellwether for neonatal surgery capacity in low resource settings? J Pediatr Surg 2016;51:1262–67.
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