A Novel Approach to Addressing Surgical Resource Scarcity in Low-Income Countries

Abstract

Background

Resource scarcity is a persistent challenge in low-income countries, significantly impacting surgical outcomes. Traditional solutions often fail to address the root causes, leading to poor patient outcomes. This study presents a novel, context-driven approach to optimize the use of limited surgical resources in rural Sudan.

Materials and Methods

A multidisciplinary team conducted a comprehensive needs assessment at a rural hospital in Sudan, identifying critical gaps in surgical capacity. Based on these findings, we implemented a multifaceted intervention that included the local production of surgical supplies, the introduction of mobile surgical teams, and the utilization of telemedicine for remote consultations. Data were collected over 12 months to evaluate the impact on surgical outcomes, resource utilization, and patient satisfaction.

Results

The intervention led to a 35% increase in the number of surgeries performed, with a significant reduction in operative delays. The local production of surgical supplies reduced dependency on external suppliers, lowering costs by 25%. The introduction of mobile surgical teams decreased patient referral rates to distant hospitals by 40%. Telemedicine consultations provided crucial specialist input in 80% of complex cases, resulting in improved decision-making and patient care.

Conclusion

This study demonstrates that a locally tailored, resource-sensitive approach can significantly enhance surgical capacity and outcomes in low-income settings. The success of this intervention suggests its potential scalability to other resource-limited regions, offering a sustainable solution to the challenges of surgical care in a changing world.

Keywords

global surgery - surgical challenges - low-income countries - mobile surgical teams - telemedicine

Surgical care is a crucial component of global health, yet access to safe, timely, and affordable surgery remains limited in many low-income countries (LICs). According to the Lancet Commission on Global Surgery, 5 billion people worldwide lack access to essential surgical services, with the greatest disparities observed in sub-Saharan Africa.[1] The barriers to effective surgical care in LICs are multifaceted, including inadequate infrastructure, shortages of trained personnel, and a lack of essential supplies.[2] These challenges are exacerbated by the reliance on external aid, which often fails to provide sustainable solutions.

Rural areas in LICs are particularly affected, where the scarcity of resources and the burden of disease are most pronounced.[2] [3] In Sudan, for instance, the surgeon-to-population ratio is approximately 3:100,000, far below the World Health Organization's (WHO) recommended minimum of 1:20,000.[4] [5] This disparity results in delayed surgeries, increased complications, and higher mortality rates. Addressing these challenges requires innovative, context-specific strategies that go beyond traditional models of care.

Study Objective

This study aims to evaluate a novel approach to addressing surgical resource scarcity in a rural Sudanese hospital. The intervention focuses on three key areas: the local production of surgical supplies, the deployment of mobile surgical teams, and the use of telemedicine for remote consultations.[6] [7] [8] [9] By integrating these components, the study seeks to enhance surgical capacity, improve patient outcomes, and reduce the dependency on external aid.

Materials and Methods

Study Design

This study was conducted as a mixed-methods intervention in three rural hospitals in Sudan. The research design included both quantitative and qualitative components to comprehensively assess the impact of the intervention on surgical outcomes, resource utilization, and patient satisfaction. The study was performed over a 12-month period, from April 2022 to April 2023.

Setting

The study took place at three district hospitals in rural Sudan, serving a population of approximately 500,000 people. The hospitals, with surgical departments comprising 23 surgeons and 10 operating theaters, faced significant resource constraints, including frequent shortages of surgical supplies, limited operating theater capacity, and a lack of specialist support.

Needs Assessment

Before implementing the intervention, a comprehensive needs assessment was conducted to identify the key challenges faced by the hospitals' surgical department. This assessment included:

1. Resource audit: Inventory of available surgical supplies, equipment, and medications.

2. Workforce analysis: Evaluation of the number, qualifications, and workload of surgical staff.

3. Patient flow assessment: Analysis of patient referral patterns, surgical waiting times, and the frequency of canceled or delayed surgeries.

4. Stakeholder interviews: Semi-structured interviews with hospital staff, patients, and community leaders to gather insights on perceived challenges and potential solutions.

The needs assessment revealed critical gaps in the availability of surgical supplies, a high workload for the limited number of surgeons, frequent referrals to distant tertiary care centers, and a lack of access to specialist consultations.

Intervention

Based on the needs assessment, a multifaceted intervention was designed and implemented, consisting of the following components:

1. Local production of surgical supplies: A partnership was established with a local manufacturing cooperative to produce basic surgical supplies such as sutures, gloves, and drapes. This initiative aimed to reduce dependency on imported supplies and lower overall costs.

2. Mobile surgical teams: To address the high referral rates and limited surgical capacity, mobile surgical teams were introduced. These teams, consisting of surgeons, anesthetists, and nurses, traveled to remote areas within the hospital's catchment area to perform surgeries on-site, thereby reducing the need for patients to travel long distances for care.

3. Telemedicine consultations: A telemedicine platform was established to facilitate remote consultations with specialists based in urban centers. This allowed the local surgical team to receive real-time advice on complex cases, improving decision-making and patient management.

Data Collection

Data were collected through multiple channels:

1. Surgical output: The number of surgeries performed, categorized by type (emergency versus elective) and complexity.

2. Resource utilization: The quantity and cost of surgical supplies used, as well as the frequency of stockouts.

3. Patient outcomes: Postoperative complication rates, length of hospital stay, and mortality rates.

4. Patient satisfaction: Structured interviews with patients to assess their satisfaction with the surgical care received.

5. Qualitative data: Feedback from hospital staff and mobile surgical teams on the feasibility and challenges of the intervention.

Data Analysis

Quantitative data were analyzed using descriptive statistics and compared with baseline data collected prior to the intervention. Qualitative data from interviews were analyzed thematically to identify common themes and insights.

Results

Surgical Output

The intervention resulted in a significant increase in surgical output. Over the 12-month period, the number of surgeries performed increased by 35%, from 1,200 in the previous year to 1,620 ([Table 1]). This increase was observed across both emergency and elective procedures, with a notable rise in the number of complex surgeries, which had previously been referred to tertiary centers ([Fig. 1]).

Table 1 Surgical output before and after intervention

Type of surgery	Baseline (2021–2022)	Intervention period (2022–2023)	Change (%)
Total surgeries	1,200	1,620	+35
Emergency surgeries	650	870	+33.8
Elective surgeries	550	750	+36.4
Complex surgeries	200	320	+60
Surgeries by mobile teams	0	240	New

Fig. 1 Number of surgeries: Baseline versus intervention.

The introduction of mobile surgical teams contributed significantly to this increase. The teams conducted 240 surgeries in remote areas, which previously would have been delayed or canceled due to the patients' inability to travel. The majority of these surgeries were related to general surgery, and trauma cases.

Resource Utilization

The local production of surgical supplies proved to be a cost-effective solution, reducing the hospital's expenditure on these items by 25% ([Table 2]). This was achieved by eliminating importation costs and reducing the reliance on international donations, which were often inconsistent and insufficient. The local manufacturing initiative also ensured a more reliable supply chain, with fewer instances of stockouts reported during the study period.

Table 2 Resource utilization and cost savings

Item	Pre-intervention (USD)	Post-intervention (USD)	Change (%)
Surgical supplies (total)	$120,000	$90,000	−25
Stockouts (monthly avg. “episode”)	5	2	−60
Locally manufactured supplies (%)	0%	70%	+70

In addition to cost savings, the initiative fostered local economic development by creating jobs within the community. The manufacturing cooperative employed 120 individuals, contributing to the local economy and increasing community engagement with the hospital.

Patient Outcomes

The intervention had a positive impact on patient outcomes. The overall postoperative complication rate decreased from 15 to 10%, and the mortality rate dropped from 2.5 to 1.8%. The reduction in complications was particularly notable in emergency surgeries, where timely intervention by the mobile surgical teams played a crucial role ([Table 3]).

Table 3 Patient outcome

Metric	Baseline	Intervention period	Change (%)
Postoperative complication rate	15%	10%	−33.3
Mortality rate	2.5%	1.8%	−28
Average length of stay (days)	7.0	4.5	−35.7

The length of hospital stays also decreased, with patients discharged on average 2.5 days earlier than before the intervention. This improvement was attributed to better preoperative planning, more timely surgeries, and enhanced postoperative care facilitated by telemedicine consultations ([Fig. 2]).

Fig. 2 Improvement in patient outcomes over 12 months.

Patient Satisfaction

Patient satisfaction was high, with 85% of patients reporting a positive experience with the surgical care they received. Key factors contributing to this satisfaction included reduced waiting times, the availability of care closer to home, and the perceived competence and compassion of the surgical teams.

Patients who received care from mobile surgical teams expressed particular appreciation for not having to travel long distances, which often posed financial and logistical challenges. The ability to receive timely surgical care within their community was a significant improvement in their healthcare experience.

Qualitative Insights

Feedback from hospital staff highlighted several strengths and challenges of the intervention. The staff appreciated the increased surgical capacity and the reduction in referral rates, which alleviated some of the pressure on the main hospital. However, they also noted the challenges of coordinating mobile surgical teams, including the need for reliable transportation and the logistical complexities of setting up temporary surgical facilities in remote areas.

The telemedicine platform was well-received, with surgeons reporting that it enhanced their confidence in managing complex cases. However, connectivity issues and occasional delays in obtaining specialist input were identified as areas for improvement.

Discussion

The findings of this study align with and contribute to existing research on improving surgical care in LICs through innovative, resource-sensitive approaches. In the following section, the results of this intervention are compared with key findings from previous studies, highlighting areas of convergence and divergence.

Impact on Surgical Capacity

The results of this study demonstrate that a locally tailored, multifaceted approach can significantly enhance surgical capacity in resource-limited settings. By addressing key barriers such as supply shortages, limited surgical workforce, and the lack of specialist support, the intervention improved both the quantity and quality of surgical care available to the rural population. This study demonstrated a 35% increase in surgical output following the implementation of mobile surgical teams, telemedicine consultations, and local production of supplies. The increase in the number of surgeries performed, particularly in complex and emergency cases, underscores the effectiveness of targeted, context-specific interventions in resource-constrained environments. Mobile surgical teams were especially beneficial in expanding access to surgery in remote areas, reducing the number of referrals to distant tertiary care centers. This increase was achieved without the need for additional permanent staff or major infrastructure investments, highlighting the potential of innovative, resource-efficient solutions. The use of mobile surgical units has been previously explored as a strategy to address surgical capacity shortages in LICs. A study found that mobile surgical camps increased access to essential surgical services in rural India, achieving a 20 to 30% increase in surgical volume over a 6-month period.[10] Similarly, an evaluation of mobile surgery units in Ethiopia reported 25% increase in surgical cases in remote regions, particularly in obstetrics and trauma.[2] These findings are consistent with the results of the current study, suggesting that mobile surgical teams can be a scalable and effective solution for rural regions. However, the increase observed in this study was slightly higher than in previous reports. This may be due to the integration of telemedicine consultations, which improved decision-making and the management of complex cases, as well as the additional benefit of locally produced surgical supplies, reducing delays due to stockouts.

Resource Utilization and Cost Reduction

The local production of surgical supplies in this study led to a 25% reduction in costs related to essential items such as sutures, gloves, and drapes. This initiative reduced dependency on external donations and imported supplies, which were often delayed or unavailable. The intervention also resulted in a more reliable supply chain, decreasing the frequency of stockouts and enhancing the hospital's ability to maintain consistent surgical services. The importance of local production of medical supplies in LICs has been highlighted by several studies. A study noted that unreliable supply chains and dependence on external aid were key barriers to consistent surgical care in sub-Saharan Africa.[3] In contrast, a study found that the local production of medical gloves and surgical gowns reduced costs by 20% and improved supply reliability by 30%.[11] The findings of this study are in line with these previous studies, reinforcing the argument that local manufacturing can be a sustainable and cost-effective solution. However, the 25% cost reduction in the current study was slightly higher than what was reported in Zambia, possibly due to the scale of production and the specific local partnerships established with the manufacturing cooperative.

Impact on Postoperative Outcomes

The intervention led to a decrease in postoperative complication rates from 15 to 10%, and a reduction in the mortality rate from 2.5 to 1.8%. These improvements were particularly significant in emergency surgeries, where timely interventions by mobile surgical teams and enhanced decision-making via telemedicine played a critical role. Shortened hospital stays were also observed, with patients discharged an average of 2.5 days earlier than before the intervention. Postoperative outcomes in LICs have been a focus of research, as high complication and mortality rates are often linked to delayed surgeries and limited perioperative care. A study found that hospitals in low-resource settings experienced postoperative complication rates of up to 20%, with higher rates observed in emergency procedures.[12] In contrast, interventions aimed at improving surgical timeliness and preoperative planning have been associated with reductions in complications and mortality. For example, the Lancet Commission on Global Surgery identified improved access to timely surgical care as a key factor in lowering postoperative mortality in LICs.[12] The reduction in complication rates and mortality in the current study aligns with these findings, demonstrating the importance of timely surgical intervention and specialist support in improving patient outcomes. The study's use of telemedicine for real-time consultations with specialists contributed to better management of complex cases, a factor not commonly explored in earlier studies, which focused more on physical interventions such as surgical camps or infrastructure improvements.

Patient Satisfaction and Access to Care

The intervention resulted in 85% of patients reporting satisfaction with the surgical care they received, particularly in terms of reduced waiting times, access to care closer to home, and the professionalism of the mobile surgical teams. The ability to receive timely surgical treatment within their community was a key factor in patient satisfaction, as many patients would have previously faced financial and logistical challenges in traveling to distant hospitals. Patient satisfaction is an important yet often overlooked metric in global surgery research. A study found that a large number of patients were satisfied with the care received through mobile surgical units, particularly in terms of reduced travel time and costs.[13] Similar findings were reported where mobile surgery programs led to an increased satisfaction rate due to the accessibility of care.[14] These studies align closely with the current findings, indicating that improving access to care in remote regions significantly enhances patient satisfaction. Additionally, the combination of mobile surgical teams and telemedicine consultations in the current study may have contributed to the slightly higher patient satisfaction rate compared with previous studies. The provision of specialist input via telemedicine likely reassured patients and increased their confidence in the quality of care they received.

Telemedicine and Specialist Support

Telemedicine played a critical role in improving decision-making for complex cases in this study. It provided crucial specialist input in 80% of challenging surgical cases, improving the confidence and capabilities of the local surgical team. Despite occasional connectivity issues, telemedicine was viewed as a valuable tool for bridging the gap between rural surgeons and urban specialists. Telemedicine is an emerging area of interest in global surgery, particularly as a means of addressing specialist shortages in LICs. A systematic review found that telemedicine programs in low-resource settings led to improved diagnostic accuracy, better decision-making, and reduced referral rates, particularly in cases requiring specialist consultations.[15] Another study demonstrated that telemedicine reduced the need for patient transfers similar to the reduction in referrals observed in the current study.[16] The findings of this study align with previous research, confirming the utility of telemedicine in improving surgical care in LICs. However, this study adds new insights by showing that telemedicine can be successfully integrated with mobile surgical teams to address both logistical and clinical challenges. This combination had not been widely explored in earlier studies, which typically focused on telemedicine as a standalone intervention.

Sustainability and Scalability

One of the key strengths of the intervention is its sustainability. The local production of surgical supplies not only reduced costs but also ensured a more reliable supply chain, lessening the hospital's dependence on external aid. This approach could be scaled to other regions with similar challenges, provided there is sufficient local capacity for manufacturing and quality control. The use of mobile surgical teams and telemedicine consultations also offers a scalable model for improving surgical care in remote areas. However, the success of these components depends on the availability of reliable transportation, communication infrastructure, and ongoing training for both surgical teams and local healthcare workers.

Challenges and Limitations

Although the intervention was successful in many respects, several challenges were encountered. The coordination of mobile surgical teams required careful logistical planning and posed risks related to transportation and the setup of temporary surgical facilities. Additionally, although telemedicine provided valuable specialist input, issues with internet connectivity occasionally hindered its effectiveness. Further research is needed to assess the effectiveness of this approach in different contexts and to identify potential adaptations that could enhance its applicability in other settings.

Policy Implications

The findings of this study have important implications for health policy in LICs. Policymakers should consider supporting the development of local production capacities for essential surgical supplies, as this approach can reduce costs, increase supply chain reliability, and contribute to local economic development.

In addition, the deployment of mobile surgical teams and the integration of telemedicine into surgical care should be explored as cost-effective strategies for improving access to surgery in remote areas. These interventions could be incorporated into national health plans and supported by targeted funding and capacity-building initiatives.

Conclusion

This study demonstrates that a context-driven, resource-sensitive approach can significantly enhance surgical capacity and outcomes in a resource-limited setting. The intervention in rural Sudan led to a substantial increase in surgical output, improved patient outcomes, and high levels of patient satisfaction. By leveraging local resources, mobile surgical teams, and telemedicine, the intervention addressed key barriers to surgical care and provided a sustainable solution to the challenges faced by rural hospitals in LICs. The success of this intervention suggests that similar strategies could be effective in other resource-limited settings, offering a scalable solution to the global challenge of surgical resource scarcity. Future research should focus on adapting and testing this approach in different contexts to further refine its effectiveness and sustainability.

This study also builds on previous research by integrating multiple innovative strategies—mobile surgical teams, local supply production, and telemedicine—into a novel cohesive model. The higher patient satisfaction rate and the success of combining telemedicine with mobile surgery represent valuable contributions to the growing body of evidence on effective surgical care in LICs.

By comparing the results with findings from other studies, this research highlights the potential for scaling up such interventions and offers insights for policymakers and healthcare providers seeking sustainable solutions to the surgical care challenges in low-resource environments.

Conflict of Interest

None declared.

Authors' Contributions

E.G. was involved in the study design, data acquisition, drafting of the article, critical revision, and final approval of the manuscript. M.M., M.E., H.S., and I.S. contributed to data acquisition and approved the final version of the manuscript. All authors have read and approved the manuscript.

Ethical Approval

The ethical approval was obtained from the ethics committee of Ministry of Health Sudan on February 11, 2022 no. 151/33. Experimental protocols were approved by Ministry of Health Sudan authority licensing committee and the study protocols were performed in accordance with the relevant guidelines applied at the hospitals.

Patients' Consent

The data used in the study were anonymized and informed consents were obtained from the participants.

Availability of Data and Materials

All data generated or analyzed during this study are included in this published article. However, some data that support the findings of this study are available from the Ministry of Health Sudan, and restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Ministry of Health Sudan.

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Publication History

Received: 21 April 2025

Accepted: 19 May 2025

Article published online:
09 June 2025