Built To Last: A Scoping Review Of Surgical Capacity Building Approaches In Conflict-affected Settings

doi: 10.52648/JoGS.1162
Built To Last: A Scoping Review Of Surgical Capacity Building Approaches In Conflict-affected Settings
Kristin Long, Kayla Pfeiffer-Mundt, Sofia Wagemaker, Alaa Ismail, Lynette Dominguez, Adam L Kushner, Christopher Hooper Lane

Global General surgery | Other | Public health | Trauma and orthopaedics

Keywords: surgery, humanitarian, conflict, capacity

SUBMITTED: 01.03.2024 PEER REVIEWED IN: United Kingdom, Singapore, United States ACCEPTED: 22.03.2024 PUBLISHED: 22.03.2024

Background: Access to safe surgery is a critical need in settings affected by armed conflict. Humanitarian organizations can temporarily fill gaps in facilities, supplies, and trained providers. However, it is critically important to build sustainable national surgical capacity as nations emerge from conflict and reconstruct society. We conducted a scoping review to synthesize the evidence on surgical capacity-building in conflict-affected settings with the goal of identifying gaps in the literature to better enable future international humanitarian organizations to support national partners in building capacity and promoting access to care. Materials and Methods: A systematic search of PubMed and Scopus was conducted, along with a review of grey literature published by surgical non-governmental organizations using keywords related to surgery, humanitarian work, and conflict settings. Results and Discussion: The literature search identified articles describing projects in general surgery, trauma, obstetrics and gynecology, cardiothoracic, vascular, ophthalmology, and reconstructive surgery across 32 countries. Capacity-building interventions identified included: one-off training sessions, on-the-job training, task-shifting, long-term skill-building projects, dedicated postgraduate training programs, and infrastructure support. Conclusions: Understanding which interventions are most effective for building long-term surgical capacity in conflict settings will require better data collection, evaluation, and sharing. The current literature does not reflect the full scope of work being conducted in the field. Organizations should ensure alignment with local needs via surgical needs assessments. Reporting on outcomes of capacity-building work was extremely limited, impeding future efforts to build surgical capacity in conflict-affected regions.


As of 2019, approximately 80 million people were displaced from their homes due to conflict and 1.8 billion people lived in states prone to conflict. [1,2] Conflict has a profound impact on the health of a population, including death and disability, destruction of health infrastructure, and wide-spread displacement. [3] Acute surgical needs in conflicts include treatment of injuries and emergency procedures like C-sections.[4] In addition, baseline population surgical needs often go unmet and may become more complex due to delays in seeking care. Local health systems are unable to cope with demands for myriad reasons: surgical capacity is often low at baseline, existing facilities face threats of direct attack, infrastructure and supply chains are disrupted, and medical personnel may be killed or displaced.

In these settings, humanitarian organizations provide much-needed supplies, infrastructure, and human resources for surgical care. While these organizations are key for supplementing capacity acutely, they do not offer a long-term solution for limited surgical capacity. Funding is often for short-term projects and there is little local accountability. Disruptions in services are common when instability forces evacuation of international personnel. When humanitarian organizations leave due to instability or the end of the project, the burden of providing follow-up care and meeting ongoing population needs falls back upon the local health system.

While both humanitarian organizations and local actors play a key role in providing surgical care to populations affected by conflict, only local actors have a long-term role. Successful rebuilding of society post-conflict depends on a functioning local health care system. Basic surgical capability saves lives, improves quality of life, and is a cost-effective intervention in low-income contexts. [5] Determining the most effective methods of building surgical capacity in conflict-affected settings is undoubtedly complex, but has important long-term implications for populations affected by war.   Recognizing that there is a demonstrable gap in evidence on surgical capacity-building in conflict-affected settings and to identify gaps in the literature to direct future research, we sought to answer two distinct questions:  What models have been employed for partnership between international humanitarian organizations and local partners to improve the ability to provide surgical services in conflict-affected settings, and what evidence exists on the effectiveness of these partnerships in building capacity?


Search strategy

A systematic search was conducted using Pubmed and Scopus using keywords related to surgery, humanitarian work, and conflict settings. The search included all obtainable titles from 1990 to 2021.  One author (KPM) reviewed all titles and abstracts. Potentially relevant articles were sought for retrieval, and titles and abstracts of all articles cited in or citing these articles were also reviewed. Two authors (KPM and SW) independently read the full-text of all retrieved articles for inclusion (Table 1). All disagreements were resolved by consensus. A search of grey literature sources was also conducted, including Reliefweb, Medicines Sans Frontiers (MSF), and the International Committee of the Red Cross (ICRC) according to their website functionality.

Search Terms used for the review included the following:

Scopus: ((relief  W/3  work )  OR  humanitarian OR (capacity W/3 building)) AND  (surgical OR surgery OR surgeon OR  c-section OR cesarian OR cesarean OR caesarean) AND ((conflict*  W/3  setting*) OR warfare OR “armed conflict” OR “conflict zone” OR “war zone” OR “post-conflict” OR “post conflict”) – 1002 total (112 unique)

PubMed: (“relief work” OR  humanitarian OR “capacity building”) AND  (surgical OR surgery OR surgeon OR  c-section OR cesarian OR cesarean OR caesarean) AND ((conflict* AND setting*) OR warfare OR “armed conflict” OR “conflict zone” OR “war zone” OR “post-conflict” OR “post conflict”) – 165 (110 unique)

Study selection and definitions

The inclusion criteria were as follows: 1) the setting is a geographic area with ongoing or recent conflict or a population displaced by such a conflict, 2) the article must include an international nonmilitary organization providing humanitarian assistance, and 3) there must be local capacity-building related to surgical care. Only articles in English were included.

Articles were excluded if they were not written in English, could not be retrieved, were not set in a known conflict area, or did not include non-military organizations providing assistance to build local capacity specific to surgical care provisions.

Surgical care was defined as those procedures that occurred in an operating room with anesthesia. Capacity-building was defined based on the World Health Organization as:

“the development of knowledge, skills, commitment, structures, systems, and leadership to enable effective health promotion. It involves … advancement of knowledge and skills among practitioners [and] expansion of support and infrastructure for health promotion…” [6]

Two broad categories of capacity-building were identified: human capacity-building and infrastructure support. Human capacity-building included training related to surgery or surgical management, and infrastructure included providing non-disposable equipment, along with building or renovating hospitals and operating rooms.

While military organizations often provide surgical care in conflict, they were excluded because resources available are different and military objectives differ from humanitarian objectives. In describing the location as active conflict, post conflict, or displaced settings, descriptions from included articles were relied upon. However, it is important to note that there is often overlap as the line between active conflict and post-conflict is often blurred, and settings with refugee and internally displaced populations often experience considerable insecurity.


Each article that met the inclusion criteria was read in its entirety and the following elements were extracted: humanitarian organization providing care, country, year published, author, title, setting (active conflict, post-conflict, or displaced), type of surgical services being provided, type of capacity-building, and measurements of impact.

Figure 1: Figure 1 – Search Results
Table 1: Locations and types of capacity-building by organization

Organization Contexts Locations Types of capacity-building Surgical Specialties
ICRC Active conflict, Displaced, Post-conflict Afghanistan, Chad, Columbia, DRC, Guinea, Lebanon, Egypt, Guinea-Bissau, Iraq, Jordan, Kenya, Libya, Mali, Myanmar, Nigeria, Palestine, Philippines, Russia, South Sudan, Syria, Somalia, Thailand War Surgery Seminars, On-the-job training (nurses, ancillary surgical staff, and doctors), postgraduate modules of war surgery training for residents, Infrastructure support (surgical equipment, operating theatres, a war surgery training center) Trauma, General, Orthopedic, Vascular
QRCS Active conflict Palestine Short training seminars (endoscopy and minimally invasive surgery), On-the-job training and supervision of physicians and, nurses, International postgraduate surgery training, Infrastructure support (medical equipment, specialized surgery building) General, Cardiothoracic, Urology, Vascular Surgery, Oncology
MSF Active Conflict, displaced Afghanistan, DRC, Chad, Liberia, Somalia, Angola, Haiti, Syria On-the-job training of physicians and nurses, task-shifting, Infrastructure support (building or renovating trauma center and O.R.s,) Trauma, general, obstetric, orthopedic
American University of Beirut Active Palestine Short-term training using telemedicine – virtually scrubbing with a portable tablet and providing real-time video and audio guidance Hand surgery
Operation Smile International Active Jordan Short-term training – transported Iraqi surgeons to view cleft lip/palate surgeries for educational purposes Plastic surgery – cleft lip / palate deformity corrective surgery
WHO Active Somalia Short-term training of doctors, nurses and midwives Trauma and OB
Columbia university mailman school for public health consortium Active Bosnia and Hergozovenia, Kenya, Liberia, Pakistan, Sierra Leone, Southern Sudan, Tanzania, Thailand, Uganda Short-term training of physicians, surgical technicians, and medical officers, Infrastructure improvements Obstetric
Medical Aid for Palestinians Active Lebanon Short-term training of doctors and nurses Trauma
Leonard Cheshire Centre of Conflict Recovery and Humar Charity Center Displaced Azerbaijan Training in management of surgical program with handover to local NGO General, obstetrics and gynecology, ENT, Ophthalmology
Shoklo malaria research unit/ aide medicale internationale Displaced Thailand Infrastructure – Establishment of a surgical service in a refugee camp Non-acute general and Ob/Gyn surgery
BethanyKids Displaced Kenya Passing expertise on to national pediatric surgeons through a disability-focused accredited pediatric surgery program Pediatric congenital and acquired surgical conditions (club foot, VP shunt, cleft lip, hypospadias, colostomy, dressing changes, contracture release)
American physicians sponsored by AHPBA, IHPBA, WSF, American Kurdish Medical Group Post Iraq Training of local surgeons including competency assessment, organization of academic surgical symposium, creation of renal transplant fellowship program, resourcing ang training on laparoscopic surgery, support of medical journal, General surgery including laparoscopic procedures, ob/gyn, renal transplant surgery, neurosurgery, oncology
Australian Aid / Royal Australian College of Surgeons Post Timor-Leste Local postgraduate training, specialty training outside country (via provision of foreign docs and scholarships), 15 years of sustained presence of resident surgeon to provide training and mentoring, training of returned specialists to be medical educators -> teaching hospital and ability of national university to provide postgraduate medical education Training by general surgeon, orthopedic, Ob/Gyn
Fred Hollows foundation new zealand, vision 2020/australian aid Post Timor-Leste International training (masters degree in medicine) and visiting specialist teams + expat advisor focused on training of local tertiary surgical staff. Also building an ophthalmology center and equipping it. Training of 20 mid-level eye care workers and 5 refractionists – mixture of cataract surgeons and general ophthalmologists Ophthalmologic – Eye / cataract surgery
German NGO Kindernothilfe, Deutche Diakonie, Nonprofit civil society group Health for the caucasus Post Russia Initial training of 2 surgeons in Germany , local surgeons assisted during in-country surgical trip – teams of two with additional surgeons observing. Seminars and hands-on training. The local surgeons progressively took on more responsibility so that 4 surgeons were enabled to perform and teach microsurgery interventions such as myringoplasties independently. Also purchase of specific equipment – operation microscope and other specialized equipment Plastic reconstructive surgery – Otologic microsurgery

Search Results

The search in Scopus and PubMed resulted in 13 articles meeting inclusion criteria, and reference review yielded 11 additional articles. Forty-seven documents were identified from grey literature sources. Articles represented 32 different countries across Africa, the Middle East, Eurasia, Southeast Asia, Southeastern Europe and the Caribbean. See image 1 for a map.

The majority of sources (55) were active conflict settings, with 4 displacement settings (refugees or internally displaced), 8 post-conflict settings, and 4 articles with multiple groups represented. Surgical specialties included general, trauma, obstetrics and gynecology, cardiothoracic, vascular, urology, ophthalmology, otologic microsurgery, and reconstructive surgery.  See table 1 for locations and types of capacity-building by organization.

Types of Capacity-Building Interventions

Capacity-building interventions were classified as short-term training, long-term training, or infrastructure improvement. Humanitarian organizations often used a combination of capacity-building modalities based on context and project needs.

Short-term training

Short-term strategies used in humanitarian settings consisted of seminars or training workshops, on-the-job training, and task-shifting. A well-developed example of training seminars are War Surgery Seminars conducted by the ICRC. These are short (typically 3 day) courses focused on trauma surgery and treatment of war-wounded patients conducted in over 20 countries every year. [7] Training seminars have also been reported by other organizations in general surgery, emergency obstetric care, and endoscopy. [8–10]

Another short-term strategy employed by humanitarian organizations is on-the-job training as part of surgical outreach trips. Multiple organizations including the ICRC and Medical Aid for Palestinians have taught trauma management skills to doctors and nurses. [11–19] Medicines Sans frontiers (MSF) has trained local community members in basic surgical nursing skills, and Operation Smile International invited local Iraqi surgeons to observe cleft lip surgeries. [20,21] One notable example of on-the-job training was a collaboration between the American University of Beirut and a hospital in Gaza, Palestine in which virtual reality technology used to remotely ‘scrub-in’ to a complex hand reconstruction surgery and provide real-time audio and video guidance. [22]

A final modality used to build capacity in the short-term is task-shifting. Task-shifting redistributes activities from higher-level to lower-level clinicians and helps with appropriate human resource allocation. Both MSF and the ICRC have supported task-shifting of basic surgical services like wound debridement to non-surgeon physicians or nurses. [7,20,23] In addition, MSF has also relied on surgical nurses to perform emergency cesarian sections in conflict settings. [20]

Long-term projects focused on capacity

Long-term capacity-building efforts have occurred either in the context of dedicated training projects or in collaboration with accredited postgraduate training programs. Training as part of projects typically includes initial training in surgical skills and management practices with progressively increasing levels of responsibility. Seven projects focused on one surgical specialty including: general surgery, trauma surgery, orthopedic fracture management, otologic microsurgery, ophthalmology, and emergency obstetric care. [24–32] In contrast, two projects conducted integrated capacity-building broadly across many surgical specialties, and one project focused solely on management by training a local NGO to coordinate visiting doctors and surgical referrals from camp settings to secondary or tertiary care institutions. [33–35]

Organizations measured success in varying ways. Many reported that they handed day-to-day project management over to local counterparts, while only a few reported quality of care or other outcome measures. Only MSF reported patient outcomes, with continued low peri-operative mortality rates in Somalia even without in-person presence, and a decrease in amputation rates on orthopedic projects in the DRC and Afghanistan. [26,27] Two projects reported new access to specific surgical services. In the Russian North Caucuses, training in otologic microsurgery increased the number of surgeons in the region able to perform and teach microsurgery interventions from zero prior to the project to four afterwards. [28,29] Obstetric training in Ugandan and Tanzanian refugee settings resulted in the capacity to consistently perform C-sections where this service had not previously been available. [30] One project reported on cost-effectiveness, with Aide Medicale Internationale in Thailand demonstrating that providing non-urgent procedures like hernias, mass excisions, and elective sterilizations in camp settings can be more cost effective than referrals out-of-camp. [32]

Postgraduate training programs

A few organizations also supported accredited training programs. In-country training programs included: a fellowship program in transplant surgery in Iraqi Kurdistan, disability-focused pediatric surgical training in Kenya, and ICRC postgraduate war surgery training in sub-Saharan Africa, Columbia, Lebanon, Egypt, Syria, and Gaza. [7,33,36] Other programs funded accredited training conducted partially or fully in neighboring countries. The Qatari Red Crescent Society funded Palestinian doctors for 4-5 years of postgraduate studies in general surgery in Qatar or Jordan. [37] In ophthalmology, the Royal Australasian College of Surgeons and Fred Hollows Foundation of New Zealand worked with national actors in Timor-Leste to establish a postgraduate diploma of ophthalmology at the national university, with supplemental training in Australia, Fiji, and Nepal. [31] Also in Timor-Leste, Australian Aid and the Royal Australian College of Surgeons supported international training in general and orthopedic surgery in Papua New Guinea, Fiji, Indonesia, or Malaysia, with an eventual transition to developing and supporting new postgraduate courses at the national university. [38]

Infrastructure support

Infrastructure and equipment support is also important, as any previously existing infrastructure may have been destroyed by conflict or may have become unusable due to lack of repairs. A number of organizations provided infrastructure such as trauma centers, operating rooms, and specialized surgical equipment. [12,14,17,23,25,39–46] It is also critical to ensure that organizations ensure proper training to use specialized equipment that may be donated, and that necessary repairs can happen locally.

Figure 2: Fig 2: Geographic range of articles

Current gaps in the literature

This review identified three key gaps in the literature to address in future surgical capacity-building work. One gap is a scarcity of needs assessments. With limited time and financial resources of humanitarian organizations, it is important to ensure that training and infrastructure are relevant to the needs of the population and skill level of healthcare workers. Nine articles reported conducting a needs assessment prior to starting projects to determine where gaps existed. [28–34,46,47] While additional projects may have conducted such assessments without reporting on it, it is entirely possible training provided in certain contexts is dependent on the experience of the organization rather than needs of the population. Greater clarity on context-specific needs would allow for better resource utilization.

Another gap is that published literature represents only a fraction of capacity-building work conducted in the field. Even when organizations report training efforts, the descriptions are vague and others are unlikely to be able to replicate activities. None of the articles in this review reported specific curricula used in training workshops or other activities. The lack of available information on project activities means there is potential for duplication of efforts between organizations. Making training efforts and curriculum content available would be beneficial for other organizations conducting similar work. Remedying this lack of available information will require commitment from organizations involved in the humanitarian response and mechanisms to share across contexts, likely facilitated by the World Health Organization or UN Humanitarian Cluster system.

A third issue is a lack of consensus on how to measure impact of capacity-building and a scarcity of evaluations. In the short-term, training workshops and seminars have an important role in continuing the medical education of providers, but take time away from clinical practice, so it is important to ensure trainings are needed and useful. While many projects reported on the number of healthcare workers attending trainings, only two projects mentioned competency assessment following such courses. [33,48] In reviewing these efforts, we propose that one-off workshops and short training courses have clearly stated learning objectives, aim to integrate with broader capacity-building strategies when possible, and evaluate and publish training results.

Since the limitations on travel imposed during the COVID pandemic, numerous strategies have been proposed to support local programs.  These include, but are not limited to, efforts such as open educational resources, synchronous/asynchronous support, and formal evaluations of local surgical team expertise.  There is very little data reported on the optimal use of any of these strategies, and ongoing research in this area is paramount for both academic institutions and non-governmental organizations.

For longer-term projects, there is also a lack of clarity on key outcomes. The ability to hand over to local staff is certainly important and was mentioned in a number of articles, however only two projects reported on patient quality of care outcomes following this handover. In addition, there were no capacity-building outcomes reported that were common across projects, which limits the ability for future projects to learn from successes and setbacks. We propose the development of common data metrics between organizations in the following domains, with the recognition that measures could certainly be expanded depending on project goals:

  1. Availability of surgical procedures in project region, particularly those that should be standard at the primary healthcare level. The ability of hospitals to perform cesarian deliveries, laparotomy, and treatment of open fractures (Bellweather Procedures) have previously been proposed for monitoring essential services in low and middle-income countries, and are likely applicable to many conflict-affected settings. [49]
  2. Patient outcome measurements including infection rates, intraoperative and post-operative mortality rates.
  3. Local project ownership and integration with any national training programs.
  4. Retention of trained staff in healthcare sector in country, given that brain-drain is a recognized challenge in many contexts.

There are a number of limitations of this scoping review. First, the limited literature available in peer-reviewed journals led to a reliance on grey literature. Grey literature sources are commonly published by humanitarian organizations who may be hesitant to report negative project outcomes. In addition, only articles explicitly describing the setting as conflict-related were included. This means there were likely interventions in countries experiencing conflict, recovering from a conflict, or hosting displaced populations that were not identified. The scarcity of interventions in post-conflict and refugee settings underlines the huge need for additional research in these settings, even compared to available literature on active conflict settings. Additionally, the language was limited to English and there may be other articles in French, Arabic, or other languages that would add to findings.


Various strategies have been used for capacity-building in conflict-affected settings, including short-term seminars, on-the-job training, task-shifting, dedicated long-term capacity projects, and formal accredited educational degrees. The majority of the available literature focuses on capacity-building in active conflict, although critical gaps remain for understanding the impact of such interventions. This review outlines three key gaps that must be addressed for more effective capacity-building work. First, organizations should ensure training programs align with local needs via surgical needs assessments. Second, greater publishing of capacity-building work and training methodologies would allow for greater collaboration and reduce duplication of efforts. Finally, common evaluation metrics would allow for learning from successes across projects. As instability and conflict continues to increase globally, international organizations must prioritize effective local capacity-building to ensure that those who need surgery are able to receive it.

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