Introduction

Globally, more than 1.75 billion children lack access to safe surgical care. In sub-Saharan Africa (SSA), more than 97% of children are without surgical access,1,2 primarily caused by the severe shortage of health workforce capacity. The current surgeon, anesthesia, and obstetrician (SAO) provider ratio in SSA is 0.46 per 100,000 people, compared to the optimal range of 20–40 providers per 100,000 people.3,4 The shortage of pediatric surgical specialists compared to population served4 contributes to elevated surgical morbidity and mortality, even for treatable childhood conditions.5,6

This workforce deficit is mirrored in many low- and middle-income countries.4,7–9 For example, in India, the Rashtriya Bal Swasthya Karyakram program identified children needing surgery; however, the limited availability of trained personnel at regional hospitals constrained service delivery.10 In response, Christian Medical College-Vellore (CMC Vellore) partnered with The Royal College of Surgeons of England and the University of Oxford to develop training for district hospital surgical teams that improves emergency and routine care, trauma management, triage, and communication between tertiary centers (hubs) and district hospitals (spokes).4,11,12 This hub-and-spoke model enhanced referral pathways and technical support for lower-level providers, markedly increasing access to pediatric surgery. Interest in this model has since increased among pediatric surgical providers in Tanzania.3,10

To address SSA’s provider shortage, international partnerships and team-based training emphasize context-specific capacity building and sustainability. In East Africa, initiatives such as the Pediatric Emergency Surgery Course in Uganda have strengthened health care providers’ skills for managing acute surgical conditions.13

The hub-and-spoke model, with its training outreach from tertiary to district facilities, has proven effective for building local surgical capacity and promoting provider retention. Further, it encourages interprofessional collaboration and knowledge exchange, thereby cultivating a resilient health care system that is better equipped to respond to pediatric surgical needs.14,15

In October 2023, Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania, hosted the first Children’s Surgery Course in Africa. The Tanzanian team, supported by Kids-OR, MNH, and the Ministry of Health, contextualized course content for regional relevance, and conducted a second course in 2024. The implications of these two courses for the adoption, implementation, outcomes, and prospects for scaling pediatric surgical training in Tanzania are outlined in this report.

Methodology

Trainer capacity building and adoption of curriculum

Planning for the first course began with Tanzanian trainers visiting CMC Vellore, in India, in 2023. The team included an anesthesiologist, pediatric and general surgeons, nurse practitioners, a pediatric neurosurgeon, a global surgery scholar, and a Ministry of Health official. They observed the implementation of training, with a focus on assessing opportunities for adaptation in Tanzania. MNH and the Ministry of Health were involved from the outset, facilitating sustainable adoption of the hub-and-spoke model. The team engaged in planning and coordination, meeting in person and via digital communication platforms.

The team distilled their experience in India to create the first Children’s Surgery Course in Tanzania. Given the shortage of pediatric surgeons outside of tertiary hospitals, the course targeted SAO providers at district-level hospitals—primarily non-physician health care professionals. The hub was MNH; spokes were regional referral hospitals surrounding Dar es Salaam.

Course objectives were: (1) to train providers in basic pediatric surgical techniques, (2) to standardize pediatric surgical care at second-level facilities, and (3) to facilitate regional knowledge exchange. The overarching goal was to ensure that children had access to surgery within 2 hours of need.

On the first day of the course, the overall vision was introduced, followed by a Trainer of Trainers (ToT) session on adult learning theory. All participants (surgeons, anesthesiologists, nurse anesthetists, nursing staff) attended foundational lectures in pediatric anatomy, the systematic approach to acutely ill children, fluid management, airway management, and pediatric trauma. Specialty-specific breakout groups were held. Participants in the pediatric surgery group engaged in case-based discussions and workshops on managing intestinal obstructions and abdominal wall defects, guided by experienced pediatric surgeons. Orthopedic participants focused on pediatric femoral and supracondylar fractures, as well as the Ponseti method for treating clubfoot, under the guidance of leading orthopedic specialists. Nursing professionals attended skill stations covering stoma care, perioperative management, and pediatric pain assessment, under the guidance of senior nursing educators and pediatric surgeons. Concurrently, anesthesiologists and nurse anesthetists used simulators in dry lab sessions to practice pediatric airway management, perioperative evaluation, premedication protocols, and fasting guidelines, supervised by expert pediatric anesthesiologists.

The second day covered hands-on clinical experiences in real health care settings. Participants rotated through specialized stations, fostering interdisciplinary teamwork and applying theoretical knowledge in a practical setting. In the general pediatric surgery stream, surgeons, anesthesiologists, and nurses collaborated in operating theatres, performing and assisting with procedures under expert mentorship. Orthopedic teams gained practical experience in patient care and surgical interventions at the Orthopedic Institute. Nursing staff actively managed pediatric patients perioperatively and postoperatively in various clinical areas, including operating theatres, wards, and neonatal intensive care units, under the support of pediatric surgeons and senior nursing professionals.

For the 2023 course, the ToT session was led by a facilitator from a high-income country, with the remainder of the training delivered by Tanzanian trainers, supported by CMC Vellore. Feedback from course participants and instructors informed the development of content and pedagogical improvements for the 2024 course. In the second iteration, while course directors provided virtual oversight, the Tanzanian team took full ownership, a reflection of successful capacity building and localization. A structured data collection framework was established to assess knowledge acquisition both before and after training, as well as to collect demographic data. Notably, surgical leads from Ethiopia and Ghana attended the 2024 course to explore adopting the model.

Results

A total of 67 participants attended the 2 courses conducted in 2023 and 2024. Other than the 2 participants from Ethiopia and Ghana, the remaining participants in the 2024 course originated from regional referral hospitals in Tanzania’s Dar es Salaam, Pwani, and Mtwara regions. These facilities were strategically chosen for their geographical proximity to MNH, their consistent practice of referring pediatric surgical patients to MNH (a pattern observed across both course offerings), and the available trainee slots. The surgical teams invited from these facilities were composed of surgery providers, anesthesia providers (predominantly nurse anesthetists), ward nurses, and theatre nurses. Although both courses drew participants from the same regional referral hospitals, the specific individuals attending each course varied, primarily due to a rotational attendance policy and participant attrition.

Participants actively engaged in providing and receiving feedback from instructors and peers through structured group discussions and Likert scale assessments. A recurring and most frequently cited need among participants was for periodic follow-up courses to achieve long-lasting impact and continuous skill refinement. The initial course duration was widely perceived as too short, with a strong consensus that a 5-day course would allow for deeper engagement with the material and more extensive hands-on practice, thereby enhancing knowledge retention and practical application.

Participants were tested on core topics before and after taking the courses. Pre-course test results indicated that only 33% of participants possessed adequate baseline knowledge, while a significant 67% demonstrated inadequate knowledge. After the course, test results showed a marked improvement, with 72% of participants achieving adequate knowledge, compared to only 28% who remained in the inadequate category. When specifically asked if the course was relevant to daily practice at their facility, an overwhelming 95% of participants strongly agreed, and 80% strongly agreed that they understood course content, affirming the program’s contextual appropriateness and instructional clarity.

A dedicated WhatsApp® group facilitated course coordination, sharing of the course manual, and continuous communication throughout the training period. Beyond the formal sessions, it fostered an ongoing professional support network, enabling consultations with specialists and peers in clinical encounters. During the period spanning the courses, the group received an average of 5–10 WhatsApp calls per month.

Discussion and Conclusion

The Children’s Surgery Course successfully met its objectives by providing comprehensive, interactive training in basic pediatric surgery skills, significantly enhancing the knowledge and practical capabilities of participants in perioperative care. To ensure sustainable improvement in children’s access to surgery in Tanzania, it is recommended that similar training programs, ideally of 5 days duration, be regularly scheduled. Furthermore, the course should be rolled out to other zonal hospitals to establish a micro hub-and-spoke model, supporting their referring regional hospitals. To sustain this expansion, ongoing collaborations between Tanzanian and international health care providers are necessary for sharing best practices and innovations, and implementing structured follow-up mechanisms to assess the long-term impact on participants’ practices and patient outcomes.

Despite the immediate gains in knowledge and skills that the courses produced, a key limitation was the initial course duration, which was widely perceived as too short for sustained knowledge acquisition and extensive hands-on practice. Ensuring consistent quality and resource mobilization for a widely scaled hub-and-spoke model, particularly in terms of diverse and consistent funding, also presents a significant challenge for long-term sustainability across the region.

Nevertheless, the program’s demonstrated effectiveness, coupled with growing regional interest from countries such as Ethiopia and Ghana, underscores its significant potential for a broader impact across SSA. The successful localization of training, with the Tanzanian team autonomously conducting the 2024 course, and the ongoing professional support facilitated by digital platforms, like the WhatsApp group, further highlights the model’s adaptability and capacity for fostering a more resilient health care infrastructure that is capable of addressing evolving pediatric demands.

Acknowledgments

We would like to thank the Ministry of Health, Community Development, Gender, Elderly and Children, Tanzania, KidsOR, and Muhimbili National Hospital for facilitating the course.

We thank the Dar course organising team for implementing the course.

We thank Dr Theresia M.K.N. and Mr Kai M.K.N. for assessing the readability and clarity of the manuscript.

Ethical Approval

The Muhimbili National Hospital Ethics and Research Committee reviewed this activity and determined it met institutional criteria for educational/service evaluation and was exempt from formal ethical review.

Written informed consent was obtained for participant data collected on course feedback and evaluation. The report adhered to the principles of the Helsinki Declaration.

Data Availability

Deidentified data are available on request from Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.

Conflict of Interest

None declared.

Funding

No external funding was sought for this research.