Henk Broekhuizen - Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
Monic Lansu - Department of Business Administration, Institute for Management Research, Radboud University, Nijmegen, The Netherlands
Jakub Gajewski - Institute of Global Surgery, Royal College of Surgeons Ireland, Dublin ۲, Ireland
Chiara Pittalis - Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin ۲, Ireland
Martilord Ifeanyichi - Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
Adinan Juma - East Central and Southern Africa Health Community, Arusha, Tanzania
Paul Marealle - Tanzania Surgical Association, Dar Es Salaam, Tanzania
Edward Kataika - East Central and Southern Africa Health Community, Arusha, Tanzania
Kondo Chilonga - Kilimanjaro Christian Medical Centre, Moshi, Tanzania
Etiënne Rouwette - Department of Business Administration, Institute for Management Research, Radboud University, Nijmegen, The Netherlands
Ruairi Brugha - Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin ۲, Ireland
Leon Bijlmakers - Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands

BackgroundScaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach. MethodsA group model building (GMB) workshop was held with ۱۸ professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model. ResultsThe CLD consists of ۵۷ variables. These include the ۴۸ variables that were obtained through the nominal group technique and those that participants added later. We identified ۶ themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are ۵ self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or ‘resistors to change:’ recurrent costs, income lost, staff stress, and brain drain. ConclusionThis study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of ‘quick fixes’ that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner.

Surgical Mentoring, District Hospital, Tanzania, Participatory Research, Systems Thinking