Incorporating Implementation Science to improve Global Surgery in the East Central and Southern Africa region

Introduction

The year 2025 marks a decade since the publication of the Lancet Commission Global Surgery, the third Disease Control Priorities, and the adoption of the 68.15 World Health Assembly resolution.^1–3 To improve surgical care, 6 surgical indicators and National Surgical Obstetric and Anesthesia Plans (NSOAPs) were developed. Since then, there has been a significant rise in academic literature on global surgery, with a particularly strong contribution from Sub-Saharan Africa.^4,5 This is an important step as many low and middle income countries (LMICs) lack adequate data on these indicators and/or NSOAPs. Despite this evidence, many people in LMICs are still lacking access to timely, safe, and affordable surgical care whenever they need. This slow progress is an obvious “evidence-to-practice” gap in surgical health care services. Meaningful and sustainable change in global surgery occurs when research evidence is not only translated into practice and policy, but also supported by strong political commitment, adequate funding, and sustained advocacy. Our ethical obligation as global surgery researchers is to ensure that the benefits of research are widely shared, especially with those who participated in research directly or indirectly.

Implementation Science in the Context of Global Surgery

Before introducing evidence-based interventions into practice and policies, the standard has been to test their effectiveness and impact in new contexts. Traditionally, randomized clinical trials (RCTs) represent a strong design within the evidence hierarchy; however, global surgery faces unique challenges that can render the RCT design difficult to implement. Some of these challenges may be due to: i) ever evolving innovations, a peculiarities in surgical techniques which may have a learning curve, ii) the bundled nature of most global surgery interventions; for example, the WHO Surgical Safety Checklist and the Enhanced Recovery After Surgery (ERAS) Protocol, iii) constant interactions of surgical interventions with multidisciplinary or interdisciplinary actors and the context in which they are applied, and iv) ethical issues surrounding randomization of participants in an effective intervention. Global surgery research is therefore limited to few designs, mainly observational, which do not rank highly within the evidence hierarchy. Furthermore, conducting RCT is resource intensive thus hindering feasibility in resource limited settings, and may not always be necessary to build a compelling case for change. The complexities surrounding the use of the RCT study design need to be recognized, and strategies developed to overcome them. The overall aim of generating evidence in surgical care is to improve surgical education, training, research and eventually ensure better patient outcomes. Implementation science (ImS) is a viable alternative approach which unlike other designs, prioritizes generalizability of findings across diverse contexts and populations (external validity). This design accounts for adapting interventions to fit contexts, rather than adopting in its original state, which may not be sustainable. The models, theories and frameworks enable understanding of the intervention/policy effectiveness as well as implementation outcomes. Feasibility, acceptability, appropriateness, cost-effectiveness, fidelity of the intervention, and sustainability are key components of the ImS study design.⁶ Well planned ImS studies can generate strong evidence and help ensure research benefits reach the broader population quickly and more effectively. ImS is a growing field of research as shown by the increased number of studies starting from 2019 to date, with a majority from United States, Europe, Canada, and Australia based researchers.⁷ A few of these studies are surgical research and focus mainly on perioperative care, safety in surgery, and ERAS interventions. This presents a great opportunity for global surgery researchers in resource limited settings, where need for ImS is higher than in resource-rich countries. ImS has also shown potential for generating innovative strategies applicable to both low- and high-resources contexts and is gaining traction among policymakers and funders.^8,9

Integrating Implementation Science in Global Surgery

In 2021, Jumbam et al called for an increased use and understanding of contextual factors affecting the scale-up of high-quality evidence in global surgical systems in LMICs.¹⁰ Our latest issue provide evidence from the region on the burden of various surgical conditions.^11–17 Elnaim et al, show how surgical health care systems can be affected by external factors, such as pandemics, culture, and political environment.¹¹ Most importantly, they showed how postoperative complication rates were reduced to levels similar to those in international reports by using guidelines customized to local needs. Integrating implementation science is effective and needs to be deliberate to ensure evidence backed policymaking as well as policy-informed research agendas. This can be done as follows: First, capacity building on ImS designs and provide understanding of when an evidence is ready for this design; Second, allocate funding for ImS research projects and those looking into putting generated evidence into practice and policy; Third, developing ImS research infrastructure and supportive context, for example regional data collection tools for audit/feedback on the impact of implemented evidence. This will help us know what works, under what condition, and on how to de-implement what doesn’t work; Fourth, global surgery has traditionally been driven by both local and international partnerships. Global surgery partnerships should be equitable, ethical, interdisciplinary, and multidisciplinary with local leadership, as this will provide room for effective engagements to obtain local knowledge. The focus must be to equip countries with necessary tools for effective decision-making to sustainable high-quality surgical services.⁵ Anything less than this is just another form of colonialism which has historically done more harm than good. Additionally, south-south partnership should be encouraged as we have seen successful examples, such as that of Pan-African Surgical Healthcare Forum, which provided opportunity for knowledge sharing to shape regional global surgery policies.^18,19 This approach has also shown that both bottom-up and top-bottom approaches are highly essential in surgical care policies. Fifth, as we work toward patient-centered care, global surgery researchers should find ways to include patient perspectives in our work. This may need provision of platforms for community engagement and patient education about the benefits of evidence-based practice. Last but not least, journals could help advance ImS through special features or issues of publication from resource-poor settings.⁸ Technical and financial support to journals like ECAJS can champion advancement of ImS given its diamond status, hence accessible to the majority of global surgery researchers from LMICs.

The Role of Regional Bodies

Although a number of initiatives to engage policy makers are in place, a lot still needs to be done. It has been reported that it takes at least 17 years to uptake interventions into practice. The COVID-19 pandemic showed us how ImS improved evidence generation, testing, implementation, and dissemination in the shortest time. The College of Surgeons of East Central and Southern Africa (COSECSA) works closely with other East Central and Southern Africa Health Community (ECSA-HC) colleges of Anesthesia (CANECSA), Obstetrics and Gynecology (ECSACOG), and Nursing and Midwifery (ECSACONM), with potential links to Ministries of Health of member states. They are well positioned to contextualize the global agenda, including the recent WHO Global Research Agenda that highlight ImS.²⁰ COSECSA has over 140 accredited training sites, a harmonized surgical training curriculum, reaching over 40% of African countries. It brings the largest network of global surgery experts both from the north and south. COSECSA serves a diverse population of patients, demanding context-sensitive, adaptive, and equity-driven approaches. This will highly benefit from ImS techniques and presents an opportunity for innovation of low-cost, scalable, and sustainable solutions which can be used in similar LMICs settings. Results of implementation science can lead to sustained improvement of routine surgical care practice and policy. This editorial urges a strategically framed research agenda focused on real world impact, application, audience reach, and optimal usage of available resources. Improving access to surgical care will help us in the attainment of the Sustainable Development Goals and ensure health for all.