Improving Access to Surgery Through Surgical Team Mentoring - Policy Lessons From Group Model Building With Local Stakeholders in Malawi.

BACKGROUND:There is much scope to empower district hospital (DH) surgical teams in low- and middle-income countries to undertake a wider range and a larger number of surgical procedures so as to make surgery more accessible to rural populations and decrease the number of unnecessary referrals to central hospitals (CHs). For surgical team mentoring in the form of field visits to be undertaken as a routine activity, it needs to be embedded in the local context. This paper explores the complex dimensions of implementing surgical team mentoring in Malawi by identifying stakeholder-sourced scenarios that fit with, among others, national policy and regulations, incentives to perform surgery, career opportunities, competing priorities, alternatives for performing surgery locally and the proximity and role of referral hospitals. METHODS:A mixed methods approach was used which combined stakeholder input - obtained through two group model building (GMB) workshops and further consultations with local stakeholders and SURG-Africa project staff - and dynamic modeling to explore policy options for sustaining and rolling out surgical team mentoring. Sensitivity analyses were also performed. RESULTS:Each of the two GMB workshops resulted in a causal loop diagram (CLD) with an array of factors and feedback loops describing the complexity of surgical team mentoring. Six implementation scenarios were defined to perform such mentoring. For each the resource requirements were identified for the institutions involved - notably DHs, CHs and the party that would finance the required mentoring trips - along with the potential for scaling up surgery at DHs under severe financial constraints. CONCLUSION:To sustain surgical mentoring, it is important that an approach of continued communication, monitoring, and (re-)evaluation is taken. In addition, an output- or performance-based financing scheme for DHs is required to incentivize them to scale up surgery.