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The neglected child-step of global health

Story progression for Surgery


PIH/IMB is starting a Surgery program

  1. What are the surgical care issues across Rwanda

  2. Why is PIH positioned well to intervene


Deep Dive into the NSOAP

  1. What is the NSOAP

  2. What is PIH’s role in the NSOAP



  1. What’s the problem

  2. What’s the solution



  1. Nurse’s roles in Surgery

  2. Motivation for a surgeon to work in Rwinwkavu

Surgery, the neglected child-step of global health: positive achievements are still possible

Whereas surgery has traditionally been a neglected part of healthcare in resource-constrained settings, recent research and evidence reveal that surgery must become a priority in strengthening health systems and improving lives in resource-limited settings[1].

In Rwanda, Surgical services are a part of the MOH-mandated emergency and essential procedures services to be availed at district hospitals and covered by community-based health insurance (CBHI); however, an estimated 58.7% of the population do not have access to safe, affordable, and timely surgical and anesthesia care[2]. The situation is worse in rural areas where the ability to provide comprehensible mandated surgical care is not quite available at Rwanda’s district hospitals.

Despite existing gaps aligning with inadequate number of well-trained personal, insufficient diagnostic tools and infrastructure for surgical interventions at the district level, Rwanda is committed to improve surgery and anesthesia care across the country.

While accompanying Rwanda in designing, building, and implementing a world-class health system, Partners in Health, known locally in Rwanda as Inshuti Mu Buzima (PIH/IMB) emphasizes the provision of equitable, accessible, and high-quality surgery to all people in need. Towards supporting Rwanda to advocate and achieve a nationwide effort in improving surgical access and care, we plan to renovate Rwinkwavu District Hospital as a Center for Excellence in Surgery and Chronic Care, through collaboration with MOH. The Center for Excellence will serve as the training grounds and opportunity model for 39 other district hospitals in Rwanda. Furthermore, this will be a learning center for medical students from the University of Rwanda and the University of Global Health Equity on the provision of high-quality surgical care in a rural, resource-constrained setting.

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Deep Dive into the NSOAP

In 2015, the Lancet Commission on Global Surgery called for the development of National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) to strengthen surgical care worldwide. NSOAP is a guiding document organized into six major domains of a health system, namely: infrastructure, service delivery, workforce, information management, finance, and governance. Rwanda has been one of the key informants and supporters of the NSOAP since its creation whereby the government has been committed to developing its NSOAP plan to improve surgical care for all Rwandans. Over the past years, the commitment, passion, and dedication of a wide range of stakeholders such as the Ministry of Health (MoH), surgeons, obstetricians, nurses, anesthetists, bioengineers, residents, and other stakeholders have helped the country to complete its NSOAP plan[3].

To operationalize Rwanda’s NSOAP, PIH/IMB has been able to support surgical patients to access surgical care at both the district and referral hospitals by emphasizing the provision of equitable care provision, to those in need.


The availability of adequate infrastructure plays a critical role in strengthening Rwanda’s surgical system. However, despite the efforts made, there is still a huge gap in the availability of adequate infrastructure to ensure effective surgical care provision at Rwinkwavu District Hospital (RDH).  According to Rwanda’s NSOAP, almost 100% of the population should have 2-hour access to a facility that can be capable to perform the bellwether procedures[4]. However, this is still a big gap at RDH, because the setup of the existing surgical wards does not allow effective surgical care provision: currently, there are only two surgical wards for in-patient surgical care, but these rooms do not allow age- or gender-sensitive during care provision, and there is only one operating room used for all operational interventions. As a result, both surgical providers and the patient do not better treatment during the care provision!

To deal with such issues, we plan to rehabilitate the current infrastructure for surgical care by supporting the construction of innovative surgical wards with appropriate beds, oxygen, and other required equipment to ensure effective surgical care delivery at the district level.


Looking at the existing shortage of surgeons, anesthetists, and obstetricians, non-surgeon clinicians such as nurses play important roles in performing Bellwether procedures at the district level. According to Dr. Andrew the current obstetrician and gynecologist at Rwinkwavu District Hospital, the outcome of surgery largely depends on the nurses as they play critical role during the service provision of surgery. Despite being the only personal to oversee all obstetric and gynecologist activities at Rwinkwavu district hospital since he has joined PIH/IMB in 2018, Dr. Andrew’s work emphasis on ensuring all individuals get the best quality of care.

"Having grown up in a rural setting, I have witnessed preventable maternal and neonatal deaths occur due to lack of skilled and specialized personnel to intervene timely. This experience has always driven me to serve the rural community despite the limited resources to perform my duties as an Obstetrician and gynecologist.” Dr Andrew

 While mentoring general practitioners and intern doctors on good surgical techniques, Dr. Andrew highlights that much emphasis should be on the recruitment, training, and retention of healthcare providers such as nurses to ensure better outcomes during the service provision of surgery and anesthesia care.  

In his address to the first assembly of the Lancet Commission, Jim Kim, the former president of the World Bank said, “Surgery is an indivisible and indispensable part of health care”. Through the support from all our partners, donors, and people like you, we believe to accomplish this by brining quality and full accessible surgical care to people with the most need. Join us in strengthening and supporting comprehensive district health systems.

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