Cultivating Rural Surgical Leaders: Insights from a Qualitative Case Study

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In Pakistan, rural areas face critical surgical workforce shortages (6 specialists/100,000 people) and infrastructural deficits, compounded by financial barriers. The Rural Surgical Leadership Program (RSLP) was designed to train general surgeons in multidisciplinary procedural and leadership skills to address these gaps. Methods This qualitative case study evaluated the RSLP through semi-structured interviews (n = 5: 3 graduates, 2 supervisors) conducted via telephone (September–October 2024). Transcripts were thematically analyzed with inductive coding, supported by reflexivity and peer debriefing to ensure rigor. Results Three themes emerged: (1) Rural facilities faced systemic challenges, including geographic isolation, absent surgical staff, and inadequate equipment. (2) RSLP graduates gained proficiency in obstetrics and trauma care but reported gaps in orthopedics and radiology. (3) Graduates demonstrated leadership, reducing urban referrals by 50–60%, mentoring staff, and optimizing workflows. Supervisors noted their impact exceeded clinical care, including community outreach and affordability initiatives. Summary and Conclusion The RSLP highlights the transformative potential of context-adapted surgical training in LMICs. Graduates’ ability to reduce referrals and revitalize rural services aligns with global models like Malawi’s COST-Africa and Australia’s Remote Vocational Training Scheme. Persistent gaps in orthopedics and radiology underscore the need for integrated simulation tools (e.g., low-cost phantoms) and telehealth for continuous mentorship. Policy recommendations include extending specialty rotations, formalizing telemedicine partnerships, and aligning curricula with WHO surgical indicators. By merging technical and leadership training, the RSLP provides a replicable framework to strengthen rural surgical systems. Sustained investment in such programs is critical to advancing equitable access to essential surgery and achieving universal health coverage in underserved regions. Rural Surgical Leadership Program Global Surgery Surgical Training Rural Healthcare LMICs Workforce Development Figures Figure 1 Introduction An estimated 5 billion individuals lack access to safe surgical and anesthesia care globally( 2 ). These unmet surgical needs stem from a shortage of financial resources, infrastructure, and surgical workforce ( 3 ). Without appropriate surgical interventions, potentially treatable conditions lead to increased morbidity and mortality, with subsequent economic, physical, and psychological effects on patients, which further burdens the health system ( 4 ). Although this challenge affects populations worldwide, low- and middle-income countries (LMICs) face disproportionate consequences of surgical inequity, requiring an estimated 143 million additional procedures to address critical healthcare gaps and improve population health ( 2 ). Approximately 62% of Pakistan’s population resides in rural areas ( 5 ). A 1983 survey of 12 district hospitals – which together provided full surgical coverage for Northern Sindh, Northern Balochistan, and the Hazara district of the North-West Frontier Province (serving a combined population of 11 million) – revealed an annual surgical rate of 124 procedures per 100,000 people in rural Pakistan. These operations spanned four medical specialties: general surgery, urology, orthopedics, and obstetrics-gynecology ( 6 ). Due to this inadequate rural infrastructure, patients are often forced to seek essential and emergency care in urban facilities. Such delays increase financial burdens and elevate risks of complications, including preventable morbidity and mortality. Pakistan faces a critical shortage of surgical professionals, with only 6 specialists (surgeons, obstetricians, anesthesiologists) per 100,000 people—far below the Lancet Commission on Global Surgery’s target of 20 per 100,000 ( 7 ). This gap is higher in rural areas, where infrastructure and specialist availability are disproportionately limited. This shortage is further exacerbated by postgraduate training that provides graduates with only brief and fragmented rotations in key subspecialties, such as obstetrics, orthopedics, pediatric surgery, and neurosurgery ( 8 , 9 ). Consequently, they are ill-equipped to handle the diverse range of emergencies that arise in rural district hospitals. To bridge this gap, the Center for Global Surgical Care implemented the Rural Surgery Leadership Program (RSLP), a year-long initiative training qualified general surgeons in high-priority DCP-3 interventions ( 10 ) across various specialties like obstetrics and gynecology, pediatric surgery, orthopedic, neurosurgery, and anesthesia disciplines, and basic radiologic interventions. The one-year program (See Fig. 1 ) , which comprises four months of competency-based training at Karachi’s urban tertiary facility, followed by four months of training in a secondary care hospital, two months of rural surgical electives, and two months of graduate-level healthcare leadership courses aimed at strengthening surgical service delivery systems. These courses run parallel throughout the year. Graduates return to rural practice after the successful completion of the fellowship, equipped to perform essential procedures and drive systemic improvements. Ongoing evaluation ensures the program aligns with rural health priorities, maximizing workforce retention and equitable surgical access. Methodology This qualitative case study employed purposive sampling to evaluate the Rural Surgical Leadership Program (RSLP) through key informant interviews (KIIs) with in-depth interviews (IDIs) of the program graduates and their rural employers. Data were collected via 40–50-minute telephone interviews (September–October 2024), transcribed verbatim, and supplemented with field notes for contextual analysis. Reflexivity was prioritized: interviews were conducted by two MBBS-trained research associates (RAs) with no prior ties to graduates, ensuring impartiality. The RAs received standardized training on semi-structured protocols and RSLP procedures to ensure contextually relevant questioning. Analysis was led by a research coordinator (RC) with psychology and health systems expertise, with bias mitigated through peer debriefing, member checking, and iterative review of RAs’ field notes. Thematic analysis was conducted using Microsoft Excel, with inductive coding to identify themes and subthemes. An independent coder cross-validated 20% of transcripts to ensure reliability. Findings were synthesized narratively to assess program impact, emphasizing participant perspectives and systemic outcomes. This approach balanced methodological rigor with reflexivity, ensuring alignment between researchers’ interpretations and graduates’ lived experiences in rural surgical practice Results Participant Characteristics: A total of five participants provided consent for participation in this study. Three of them were graduates from the Rural Surgical Leadership Program (RSLP) at the Aga Khan University. Two were the current supervisors of the RSLP graduates working in various rural settings. Among the three RSLP graduates, two were male and one was female. Both male RSLP graduates are currently employed in remote rural areas of Pakistan —one in Buni, Chitral and the other in Singel, Gilgit. Notably, all three RSLP graduates have successfully completed their General Surgery training requirements, as stipulated by the College of Physicians and Surgeons of Pakistan (CPSP). Thematic Analysis: This study identified three broad themes which were further divided into sub-themes. The main findings, along with the themes are summarized in Table-1 (Attached in Appendix 1) : Theme 1: Readiness and Accessibility of Healthcare Facilities in Rural Areas for Surgical Procedures There are multiple, overlapping barriers undermining surgical care in Pakistan’s rural regions. First, patients face severe transportation and financial hurdles. Long journeys over difficult terrain, high travel costs, and days spent waiting in overcrowded government hospitals all delay or deny timely treatment. Second, the surgical workforce is critically thin—many facilities lack any trained general surgeons, forcing even basic procedures to be referred elsewhere. Third, essential equipment for lifesaving operations is often absent, and in some facilities, anesthesia is administered by surgeons or technicians rather than qualified anesthesiologists. All participants spoke from deep personal experience about these constraints. One described the struggle in their home village: When I visit my village, there is a huge line of surgical patients with advance cancers but when it comes to helping them, I do not have any way to do so except directing them to already existing services which have their own problems. Traveling, waiting hours to be seen in a government hospital and possibly be told to come another day. These accessibility issues are not isolated incidents. Rural hospitals are accessible by road. However, most people do not have means of transport. This necessitates patients having to plan arduous and expensive journeys just to access surgical care. Even after reaching the hospital, care remains limited, and additional travel may be necessary. A trainee at one such center shared their experiences: One of the main issues was accessibility, the closest healthcare center is 2 hours from the existing hospital. People would be coming from as far as six hours away to reach the nearest hospital which was in Gilgit City. Moreover, the health centers in remote rural areas only provided limited care to a small number of patients, primarily focusing on c-sections and natural births. A supervisor of the RSLP graduate mentioned: Before COVID, we were the only hospital in the district with a working OR mostly used by the obstetricians and gynecologist s. Without a full surgical staff, however, even these limited services falter and facilities struggle to manage even routine surgical cases. This workforce gap compels rural centers to delay care or refer patients to distant urban hospitals, further exacerbating delays and adverse health outcomes: The biggest challenge is that we didn’t have a trained surgeon, and the cases which we commonly see are obstructions, hernias, gallbladder problems, and thyroid problems that need surgery. We also see trauma cases which need trained surgeons. Some facilities go years without any general surgeon on staff. At Singel Hospital, none had been employed for seven years, leaving essential services entirely out of reach: When I came to work at the hospital, they did not have a general surgeon for the last seven years, so many things were not available. Even when clinicians are willing, the absence of critical equipment like ventilators, burr hole kits, sterilization facilities, and diagnostic ultrasound—means most centers can only provide symptomatic or clinical management before sending patients on to tertiary hospitals: Rural health care sees symptomatic management before referring to another specialty. For instance, we would not be able to treat a patient with a head injury because rural centers do not have CT scans or burr hole machines to manage patients. Management is done on a clinical basis then further care is carried out by tertiary care hospitals . Clinicians accustomed to diagnostic tools find themselves reverting to fundamental clinical skills to fill the gap: “ I was coming from a patient care center which was a lot more reliant on diagnostics. There were no CT scans, no MRIs, no ultrasounds. I had to rely on clinical skills to compensate for the absence of materials.” Theme 2: Comprehensive specialty-specific training in the RSLP program. The RSLP program provided graduates, specifically general surgeons, with comprehensive and specialized training in high-priority surgical areas such as cesarean sections, prostatectomies, common orthopedic procedures, radiology, pediatric surgeries, and anesthesia. This intensive training enhanced their ability to effectively address critical surgical needs in underserved regions, allowing them to perform essential procedures independently while simultaneously improving healthcare accessibility for rural communities. According to one RSLP trainee, The multiple surgical specialties I have been exposed to were designed in a manner that required me to attend clinics as well as operations. This ensured I developed pre-op skills, post-op inpatient management, and post-op outpatient management. I gained exposure to the common surgical aspects of those subspecialties and how to manage them. While the graduates felt well-prepared, certain gaps in their training were identified, particularly in the areas of orthopedics and radiology. As one participant remarked: In Gilgit I became confident in performing emergency cesarean section. In orthopedics I do not feel I obtained substantial exposure considering what is expected of me. What I felt was missing was the radiology and orthopedic section although they may have been my own shortcomings. There should be more focus on hands on exposure for those sections so that we meet those objectives. Another fellow added: I feel that my understanding of orthopedics is lacking because the material was rushed, and I was not adequately taught the implications. In essence, all RSLP trainees reported that they received sufficient training in the majority of the surgical skills necessary for the program. However, they suggested that more time could have been allocated to enhancing their skills in orthopedic and radiological specialties. Theme 3: Leadership and Governance abilities of RSLP Graduates Two out of the three RSLP graduates are currently practicing in a rural setting. Their contributions to rural healthcare settings have been remarkable. They demonstrated leadership with a clear vision when they joined their respective healthcare facilities. At their facilities, they organized capacity-building workshops for the workforce and promoted collaborative approaches to enhance patient care. When we spoke to the supervisors, they unanimously praised their contributions, particularly in high-pressure environments such as the emergency room. One supervisor remarked: There have been multiple incidents especially in the ER. We often have trauma cases presenting due to our environment and [RSLP Graduate] has been able to handle that along with the ER team and nurses. He is often involved in non-surgical departments helping the team manage cases. He has left a local and public impact because he takes up multiple roles in a small place. RSLP graduates who were trained for specialty specific procedures during residency were unable to perfect their skills in their rotations. However, they were able to get better exposure and perform the procedures, with and without supervision, during the RSLP program. “ Cesarean section I was not familiar with initially. Now I have performed 50 of them within 6 months. We do have a trained gynecologist, but they cannot independently perform cesarean sections in circumstances such as previous cesarean history. ” (RSLP graduate) Due to their adaptability across various specialties, the RSLP graduates have made a significant impact in their current rural practices. Their remarkable ability to tackle “city standard” procedures, which were previously considered impossible in remote facilities, has been a notable achievement. Their supervisor reported: Surgical care which seems basic and common in a city were a challenge for us. For instance, we perform laparotomy’s only in some emergencies because we do not have an ICU and because of the distance from the city. [RSLP graduate] has been able to handle procedures here that we could not imagine were possible here including plastics, vascular, orthopedics and oncology. Because of their versatility, these graduates have dramatically reduced the need to transfer patients to distant urban centers. As one supervisor estimates: “ I would say almost 50–60% of the cases coming in would have been referred to other distant hospitals if [RSLP graduate] was not here. ” (RSLP supervisor) “ The impression of services he has created here will be a huge gap to fill if he ever leaves, he is equivalent to the work of 5 surgeons. We are thankful that he is on our team and attribute our success to his efforts. ” (RSLP supervisor) Beyond direct patient care, RSLP graduates have revitalized entire departments: reorganizing staff rosters, optimizing bed allocations, ensuring equipment availability, and overhauling medication stock management. They have even taken their work into the community, conducting outreach sessions to inform residents about available surgical and emergency services at the rural health center. The RSLP graduates have actively taken part in being mentors for other doctors in their respective rural health facilities and not being afraid to ask for help when needed. “ Definitely, he was doing those things very well, working with good teamwork, including almost everyone, supervising the juniors, and asking for help from seniors whenever needed.” (RSLP supervisor) Notably, all trainees noted a significant improvement in their soft skills, including effective communication with both team members and patients, as well as managing hospital operations and emergencies. “ There have been improvements if I were to compare myself to the past. Before RSLP I was unable to talk independently or connect with patients with empathy. RSLP has helped me in communicating with patients.” (RSLP Trainee) Both the current supervisors of the RSLP graduates seem happy with the amount of mentoring and supervision being given by the graduates to their junior doctors, one supervisor stated: I would say I am positive about him doing a good job in that regard. When it comes to supervising a junior, teaching them something, and addressing any problems they bring to him, he is doing well. The graduates have so far managed to train the healthcare workers in CPR, post-operation management, and have taught junior doctors about wound care in their respective facilities. One supervisor stated: He has played a major role in improving the skills of the staff. He does lectures on surgical and non-surgical topics such as dosages of medications. He has conducted hands on CPR practices and created code scenarios to simulate . Furthermore, one of the RSLP graduates has actively taken initiative to make healthcare more affordable and accessible in the rural area he serves in. He shared: I had to see ways to finance that and create awareness. It takes time because a change in mindset was required, building trust in the community for your surgical skills takes time. Finally, RSLP graduates have forged strong partnerships with local government and healthcare leaders. These partnerships involve collaborating with existing healthcare leaders in the community and the government in their local areas to enhance healthcare services. Additionally, graduates have actively engaged with the community to address healthcare-related issues and improve overall well-being.2 “ Forming partnerships with the government and collaborating with other healthcare providers after collaborating is also crucial for forming a system where surgical care can be provided in rural settings.” (RSLP graduate) Speaking about how a RSLP graduate brought his vision to life through different collaboration, his supervisor stated: The main challenge was financing the surgeries, bringing it within the reach of patients to avail. [RSLP graduate] developed and discussed models with the finance team, in which the fee surgeons’ fees were minimal, and the hospital would not go into loss for each procedure. Through visionary leadership, clinical excellence, and collaborative governance, these RSLP graduates not only revived surgical services in their rural posts but also established a self-sustaining, community-centered model of care. Discussion Rural surgical programs are essential for addressing the healthcare needs of rural communities, which often face a shortage of medical professionals, including surgeons ( 11 ). This qualitative evaluation of the Rural Surgical Leadership Program (RSLP) highlights its role in addressing surgical inequities in rural Pakistan through workforce development, skill enhancement, and systemic reform. Key findings reveal that rural healthcare facilities face entrenched barriers—geographic isolation, financial constraints, critical shortages of trained surgeons, and inadequate diagnostic and surgical equipment—which collectively undermine surgical capacity and readiness. The findings align with global literature on rural healthcare in low and middleincome countries (LMICs), where geographic isolation, workforce shortages, and infrastructural deficits disproportionately affect surgical access ( 12 , 13 ). The RSLP successfully equipped graduates with multidisciplinary procedural skills—spanning obstetrics, trauma, orthopedics, and anesthesia—enabling them to perform essential surgeries and reduce patient referrals to urban centers by 50–60%. However, gaps persisted in orthopedic and radiological training, signaling opportunities for curricular refinement. Beyond technical competence, graduates demonstrated transformative leadership by revitalizing rural facilities through staff mentorship, operational restructuring, and community engagement, while collaborating with local governments to improve care affordability and accessibility. Our study findings align with and reinforce the Lancet Commission on Global Surgery’s call to integrate surgical care into national health systems as a cornerstone of universal health coverage ( 12 ). Comparable international initiatives have likewise improved rural surgical capacity. For example, in Malawi, the COSTAfrica program trained clinical officers via a 36month curriculum—yielding a 74% increase in district major surgeries, a rise from 31.3–61.2% of general cases performed by trained officers, postoperative wound infections of 2.3% versus 8%, and zero surgical deaths across 5,590 procedures( 14 ). Furthermore, in New Zealand, Ashburton Hospital’s shift to a rural generalist model reduced senior surgeon fulltime equivalents by 40%, increased resident medical staff by 60%, doubled acute assessment presentations, boosted highacuity cases by 152%, and cut acute length of stay by 18% despite a 62% rise in tertiary admissions ( 15 ). In Australia, their Remote Vocational Training Scheme achieved high retention among rural generalists, enhanced professional confidence, and improved competence through distance mentorship and peer networking ( 16 ). Reflecting these models, the RSLP’s yearlong blended approach—four months of competencybased urban tertiary training followed by supervised rural placement—ensured surgeons developed both technical proficiency and contextual understanding before deployment. Graduates reported a 50–60% reduction in referrals to urban centers, mirroring the 35% increase in district surgeries seen in COSTAfrica ( 14 ) and the enhanced retention reported by RVTS alumni ( 16 ). By enabling onsite delivery of highpriority DCP-3 interventions, the RSLP alleviated patient travel costs and reduced morbidity from delayed care, demonstrating the impact of contextspecific training on service continuity. Beyond surgical skills, the RSLP integrated graduatelevel leadership coursework that empowered surgeons to lead capacitybuilding workshops, optimize supply chains, and mentor junior staff—interventions aligned with the World Health Organization’s health system building blocks for service delivery, workforce, and governance ( 17 ). These reforms fostered local ownership of surgical services, strengthened interdepartmental collaboration, and secured sustainable financing through government partnerships. Similar Canadian global surgery partnerships have underscored the value of leadership training within clinical curricula to promote program sustainability and policy advocacy ( 18 ). Despite these successes, participants identified deficiencies in orthopedics and radiology exposure—skills that typically require extensive practice to master. Simulation-based orthopedic interventions—such as low-cost phantom models for fracture stabilization (30% fewer procedural errors), pediatric fracture simulators, and modular workshops with locally manufacturable devices (25% faster assembly)—paired with digital platforms like the IGOT Learning Portal, have enhanced technical proficiency ( 19 – 22 ). In radiology, gelatin-based ultrasound phantoms, which have improved needle accuracy by 50%, tele-imaging systems, which have accelerated diagnosis times by 60%, and teleradiology workshops, which have enhanced interpretation accuracy by 45%, showcase how cost-effective, context-adapted tools and digital solutions address training gaps. ( 23 – 25 ). To optimize the RSLP model, we recommend extending specialty rotations in orthopedics and radiology with integrated lowcost simulation ( 26 ); formalizing telehealth integration for continuous mentorship and case review ( 27 , 28 ); aligning the curriculum with global surgery competencies and WHO core indicators for standardized evaluation ( 29 ); augmenting leadership modules with training in health financing, advocacy, and stakeholder engagement ( 17 ); and partnering with ministries of health to embed rural surgical training within national budgets and explore slidingscale fee models to ensure affordability and sustainability. Telemedicine platforms in LMICs have supported postoperative followup, remote case consultations, and multidisciplinary discussions—reducing isolation and improving outcomes ( 27 ). More structured tele mentoring interventions, evaluated in AOS Open, demonstrated moderate to strong evidence for enhancing surgical knowledge and competence among practicing surgeons, positively influencing decisionmaking and technical performance ( 28 ). Conclusion The Rural Surgical Leadership Program (RSLP) combines context-specific, competency-based surgical training with leadership development, simulation, telehealth and rigorous evaluation to address rural workforce shortages and systemic inequities in low-resource settings. Its graduates—proficient across obstetrics, trauma and multidisciplinary care—have cut urban referrals by over 50% while highlighting persistent gaps in orthopedics and radiology that demand enhanced simulation and telehealth tools. By aligning with WHO surgical indicators and Lancet Commission targets, forging government and community partnerships and implementing subsidized surgical models, the RSLP offers a scalable, affordable blueprint for strengthening rural surgical capacity and advancing universal access to safe, timely and affordable surgery in LMICs. Sustained investment in such blended training models is essential to close the procedure gap and reduce the economic and mortality burdens of unmet surgical needs. Abbreviations AKU Aga Khan University CPSP College of Physicians and Surgeons of Pakistan CT Computed Tomography DCP-3 Disease Control Priorities, 3rd Edition ER Emergency Room ICU Intensive Care Unit IDIs In-depth Interviews KIIs Key Informant Interviews LMICs Low- and Middle-Income Countries MBBS Bachelor of Medicine, Bachelor of Surgery MRI Magnetic Resonance Imaging OR Operating Room RAs Research Associates RC Research Coordinator RSLP Rural Surgical Leadership Program WHO World Health Organization Declarations Ethics Approval and Consent to Participate This study was approved by the Ethical Review Committee of the Aga Khan University (Reference #: 2024-10448-30996) and conducted in accordance with the principles of the Declaration of Helsinki. Verbal informed consent was obtained from all five interviewees prior to participation. Consent for Publication We have consent for publication from all the listed authors and the interviewees. Availability of Data and Materials The datasets generated during this study are presented in Table 1 of Appendix 1. They were coded and analyzed. The questionnaires administered to trainees and their employers are also provided in the appendix section. All data were derived exclusively from interviews conducted by the research team at Aga Khan University. Competing Interests The authors declare no competing interests. Funding This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ Contributions • Sharjeel Ahmad, Mohammad Kumael Azhar, and Muhammad Uzair: Conceptualized the study, drafted the manuscript, and contributed to critical revisions. • Sadaf Khan, Saleema Begum, and Zeeshan Nasir Rifat: Designed and implemented the RSLP program. • Sharjeel Ahmad, Sadaf Khan, Saleema Begum, and Zeeshan Nasir Rifat: Developed the interview guide, conducted interviews, and performed data validation. • Bilal Ahmed Lodhi and Sofia Chugtai: Transcribed interviews and contributed to the methodology section. • Syed Mahnoor Shah: Performed qualitative data analysis and constructed the results table. • Sharjeel Ahmad: Designed and prepared the study figure. Acknowledgements The authors express their gratitude to the RSLP participants and their employers. References World Medical Association Declaration of Helsinki. JAMA. 2013 Nov 27;310(20):2191. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. 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Educational Effectiveness of Telementoring as a Continuing Professional Development Intervention for Surgeons in Practice: A Systematic Review. Annals of Surgery Open. 2023 Dec;4(4):e341. O’Flynn E, Danial A, Gajewski J. Global Surgery Education and Training Programmes—a Scoping Review and Taxonomy. Indian Journal of Surgery. 2022 Apr 25;84(S1):193–206. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":142176,"visible":true,"origin":"","legend":"\u003cp\u003eStructure of the RSLP Program\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6583649/v1/8051d68dd450c664ee31a19b.jpeg"},{"id":108437641,"identity":"182f2e2d-3190-40bb-b920-234d24439ba5","added_by":"auto","created_at":"2026-05-04 16:01:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":381506,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6583649/v1/27c1b06c-4787-4079-aad4-97aebd281ab4.pdf"},{"id":85843655,"identity":"feae7dc2-bd4c-4896-af66-c31818bfad66","added_by":"auto","created_at":"2025-07-02 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These unmet surgical needs stem from a shortage of financial resources, infrastructure, and surgical workforce (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Without appropriate surgical interventions, potentially treatable conditions lead to increased morbidity and mortality, with subsequent economic, physical, and psychological effects on patients, which further burdens the health system (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although this challenge affects populations worldwide, low- and middle-income countries (LMICs) face disproportionate consequences of surgical inequity, requiring an estimated 143\u0026nbsp;million additional procedures to address critical healthcare gaps and improve population health (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eApproximately 62% of Pakistan\u0026rsquo;s population resides in rural areas (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). A 1983 survey of 12 district hospitals \u0026ndash; which together provided full surgical coverage for Northern Sindh, Northern Balochistan, and the Hazara district of the North-West Frontier Province (serving a combined population of 11\u0026nbsp;million) \u0026ndash; revealed an annual surgical rate of 124 procedures per 100,000 people in rural Pakistan. These operations spanned four medical specialties: general surgery, urology, orthopedics, and obstetrics-gynecology (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Due to this inadequate rural infrastructure, patients are often forced to seek essential and emergency care in urban facilities. Such delays increase financial burdens and elevate risks of complications, including preventable morbidity and mortality.\u003c/p\u003e \u003cp\u003ePakistan faces a critical shortage of surgical professionals, with only 6 specialists (surgeons, obstetricians, anesthesiologists) per 100,000 people\u0026mdash;far below the Lancet Commission on Global Surgery\u0026rsquo;s target of 20 per 100,000 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This gap is higher in rural areas, where infrastructure and specialist availability are disproportionately limited. This shortage is further exacerbated by postgraduate training that provides graduates with only brief and fragmented rotations in key subspecialties, such as obstetrics, orthopedics, pediatric surgery, and neurosurgery (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Consequently, they are ill-equipped to handle the diverse range of emergencies that arise in rural district hospitals.\u003c/p\u003e \u003cp\u003eTo bridge this gap, the Center for Global Surgical Care implemented the Rural Surgery Leadership Program (RSLP), a year-long initiative training qualified general surgeons in high-priority DCP-3 interventions (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) across various specialties like obstetrics and gynecology, pediatric surgery, orthopedic, neurosurgery, and anesthesia disciplines, and basic radiologic interventions. The one-year program \u003cem\u003e(See\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e, which comprises four months of competency-based training at Karachi\u0026rsquo;s urban tertiary facility, followed by four months of training in a secondary care hospital, two months of rural surgical electives, and two months of graduate-level healthcare leadership courses aimed at strengthening surgical service delivery systems. These courses run parallel throughout the year. Graduates return to rural practice after the successful completion of the fellowship, equipped to perform essential procedures and drive systemic improvements. Ongoing evaluation ensures the program aligns with rural health priorities, maximizing workforce retention and equitable surgical access.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis qualitative case study employed purposive sampling to evaluate the Rural Surgical Leadership Program (RSLP) through key informant interviews (KIIs) with in-depth interviews (IDIs) of the program graduates and their rural employers. Data were collected via 40\u0026ndash;50-minute telephone interviews (September\u0026ndash;October 2024), transcribed verbatim, and supplemented with field notes for contextual analysis. Reflexivity was prioritized: interviews were conducted by two MBBS-trained research associates (RAs) with no prior ties to graduates, ensuring impartiality. The RAs received standardized training on semi-structured protocols and RSLP procedures to ensure contextually relevant questioning. Analysis was led by a research coordinator (RC) with psychology and health systems expertise, with bias mitigated through peer debriefing, member checking, and iterative review of RAs\u0026rsquo; field notes.\u003c/p\u003e\u003cp\u003eThematic analysis was conducted using Microsoft Excel, with inductive coding to identify themes and subthemes. An independent coder cross-validated 20% of transcripts to ensure reliability. Findings were synthesized narratively to assess program impact, emphasizing participant perspectives and systemic outcomes. This approach balanced methodological rigor with reflexivity, ensuring alignment between researchers\u0026rsquo; interpretations and graduates\u0026rsquo; lived experiences in rural surgical practice\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA total of five participants provided consent for participation in this study. Three of them were graduates from the Rural Surgical Leadership Program (RSLP) at the Aga Khan University. Two were the current supervisors of the RSLP graduates working in various rural settings. Among the three RSLP graduates, two were male and one was female. Both male RSLP graduates are currently employed in remote rural areas of Pakistan \u0026mdash;one in Buni, Chitral and the other in Singel, Gilgit. Notably, all three RSLP graduates have successfully completed their General Surgery training requirements, as stipulated by the College of Physicians and Surgeons of Pakistan (CPSP).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThematic Analysis:\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study identified three broad themes which were further divided into sub-themes. The main findings, along with the themes are summarized in Table-1\u003cem\u003e(Attached in Appendix 1)\u003c/em\u003e:\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eTheme 1: Readiness and Accessibility of Healthcare Facilities in Rural Areas for Surgical Procedures\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThere are multiple, overlapping barriers undermining surgical care in Pakistan\u0026rsquo;s rural regions. First, patients face severe transportation and financial hurdles. Long journeys over difficult terrain, high travel costs, and days spent waiting in overcrowded government hospitals all delay or deny timely treatment. Second, the surgical workforce is critically thin\u0026mdash;many facilities lack any trained general surgeons, forcing even basic procedures to be referred elsewhere. Third, essential equipment for lifesaving operations is often absent, and in some facilities, anesthesia is administered by surgeons or technicians rather than qualified anesthesiologists. All participants spoke from deep personal experience about these constraints. One described the struggle in their home village:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen I visit my village, there is a huge line of surgical patients with advance cancers but when it comes to helping them, I do not have any way to do so except directing them to already existing services which have their own problems. Traveling, waiting hours to be seen in a government hospital and possibly be told to come another day.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThese accessibility issues are not isolated incidents. Rural hospitals are accessible by road. However, most people do not have means of transport. This necessitates patients having to plan arduous and expensive journeys just to access surgical care. Even after reaching the hospital, care remains limited, and additional travel may be necessary. A trainee at one such center shared their experiences:\u003c/p\u003e \u003cp\u003e \u003cem\u003eOne of the main issues was accessibility, the closest healthcare center is 2 hours from the existing hospital. People would be coming from as far as six hours away to reach the nearest hospital which was in Gilgit City.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMoreover, the health centers in remote rural areas only provided limited care to a small number of patients, primarily focusing on c-sections and natural births. A supervisor of the RSLP graduate mentioned:\u003c/p\u003e \u003cp\u003e \u003cem\u003eBefore COVID, we were the only hospital in the district with a working OR mostly used by the obstetricians and gynecologist\u003c/em\u003es.\u003c/p\u003e \u003cp\u003eWithout a full surgical staff, however, even these limited services falter and facilities struggle to manage even routine surgical cases. This workforce gap compels rural centers to delay care or refer patients to distant urban hospitals, further exacerbating delays and adverse health outcomes:\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe biggest challenge is that we didn\u0026rsquo;t have a trained surgeon, and the cases which we commonly see are obstructions, hernias, gallbladder problems, and thyroid problems that need surgery. We also see trauma cases which need trained surgeons.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome facilities go years without any general surgeon on staff. At Singel Hospital, none had been employed for seven years, leaving essential services entirely out of reach:\u003c/p\u003e \u003cp\u003eWhen \u003cem\u003eI came to work at the hospital, they did not have a general surgeon for the last seven years, so many things were not available.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eEven when clinicians are willing, the absence of critical equipment like ventilators, burr hole kits, sterilization facilities, and diagnostic ultrasound\u0026mdash;means most centers can only provide symptomatic or clinical management before sending patients on to tertiary hospitals:\u003c/p\u003e \u003cp\u003e \u003cem\u003eRural health care sees symptomatic management before referring to another specialty. For instance, we would not be able to treat a patient with a head injury because rural centers do not have CT scans or burr hole machines to manage patients. Management is done on a clinical basis then further care is carried out by tertiary care hospitals\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eClinicians accustomed to diagnostic tools find themselves reverting to fundamental clinical skills to fill the gap: \u0026ldquo;\u003cem\u003eI was coming from a patient care center which was a lot more reliant on diagnostics. There were no CT scans, no MRIs, no ultrasounds. I had to rely on clinical skills to compensate for the absence of materials.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Comprehensive specialty-specific training in the RSLP program.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe RSLP program provided graduates, specifically general surgeons, with comprehensive and specialized training in high-priority surgical areas such as cesarean sections, prostatectomies, common orthopedic procedures, radiology, pediatric surgeries, and anesthesia. This intensive training enhanced their ability to effectively address critical surgical needs in underserved regions, allowing them to perform essential procedures independently while simultaneously improving healthcare accessibility for rural communities.\u003c/p\u003e \u003cp\u003eAccording to one RSLP trainee,\u003c/p\u003e \u003cp\u003eThe multiple surgical specialties I have been exposed to were designed in a manner that required me to attend clinics as well as operations. This ensured I developed pre-op skills, post-op inpatient management, and post-op outpatient management. I gained exposure to the common surgical aspects of those subspecialties and how to manage them.\u003c/p\u003e \u003cp\u003eWhile the graduates felt well-prepared, certain gaps in their training were identified, particularly in the areas of orthopedics and radiology. As one participant remarked:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIn Gilgit I became confident in performing emergency cesarean section. In orthopedics I do not feel I obtained substantial exposure considering what is expected of me. What I felt was missing was the radiology and orthopedic section although they may have been my own shortcomings. There should be more focus on hands on exposure for those sections so that we meet those objectives.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnother fellow added:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI feel that my understanding of orthopedics is lacking because the material was rushed, and I was not adequately taught the implications.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn essence, all RSLP trainees reported that they received sufficient training in the majority of the surgical skills necessary for the program. However, they suggested that more time could have been allocated to enhancing their skills in orthopedic and radiological specialties.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eTheme 3: Leadership and Governance abilities of RSLP Graduates\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTwo out of the three RSLP graduates are currently practicing in a rural setting. Their contributions to rural healthcare settings have been remarkable. They demonstrated leadership with a clear vision when they joined their respective healthcare facilities. At their facilities, they organized capacity-building workshops for the workforce and promoted collaborative approaches to enhance patient care.\u003c/p\u003e\u003cp\u003eWhen we spoke to the supervisors, they unanimously praised their contributions, particularly in high-pressure environments such as the emergency room. One supervisor remarked:\u003c/p\u003e\u003cp\u003e\u003cem\u003eThere have been multiple incidents especially in the ER. We often have trauma cases presenting due to our environment and [RSLP Graduate] has been able to handle that along with the ER team and nurses. He is often involved in non-surgical departments helping the team manage cases. He has left a local and public impact because he takes up multiple roles in a small place.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eRSLP graduates who were trained for specialty specific procedures during residency were unable to perfect their skills in their rotations. However, they were able to get better exposure and perform the procedures, with and without supervision, during the RSLP program.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eCesarean section I was not familiar with initially. Now I have performed 50 of them within 6 months. We do have a trained gynecologist, but they cannot independently perform cesarean sections in circumstances such as previous cesarean history.\u003c/em\u003e\u0026rdquo; \u003cem\u003e(RSLP graduate)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDue to their adaptability across various specialties, the RSLP graduates have made a significant impact in their current rural practices. Their remarkable ability to tackle \u0026ldquo;city standard\u0026rdquo; procedures, which were previously considered impossible in remote facilities, has been a notable achievement. Their supervisor reported:\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurgical care which seems basic and common in a city were a challenge for us. For instance, we perform laparotomy\u0026rsquo;s only in some emergencies because we do not have an ICU and because of the distance from the city. [RSLP graduate] has been able to handle procedures here that we could not imagine were possible here including plastics, vascular, orthopedics and oncology.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBecause of their versatility, these graduates have dramatically reduced the need to transfer patients to distant urban centers. As one supervisor estimates:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI would say almost 50\u0026ndash;60% of the cases coming in would have been referred to other distant hospitals if [RSLP graduate] was not here.\u003c/em\u003e\u0026rdquo; \u003cem\u003e(RSLP supervisor)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe impression of services he has created here will be a huge gap to fill if he ever leaves, he is equivalent to the work of 5 surgeons. We are thankful that he is on our team and attribute our success to his efforts.\u003c/em\u003e\u0026rdquo; \u003cem\u003e(RSLP supervisor)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBeyond direct patient care, RSLP graduates have revitalized entire departments: reorganizing staff rosters, optimizing bed allocations, ensuring equipment availability, and overhauling medication stock management. They have even taken their work into the community, conducting outreach sessions to inform residents about available surgical and emergency services at the rural health center.\u003c/p\u003e\u003cp\u003eThe RSLP graduates have actively taken part in being mentors for other doctors in their respective rural health facilities and not being afraid to ask for help when needed.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eDefinitely, he was doing those things very well, working with good teamwork, including almost everyone, supervising the juniors, and asking for help from seniors whenever needed.\u0026rdquo; (RSLP supervisor)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eNotably, all trainees noted a significant improvement in their soft skills, including effective communication with both team members and patients, as well as managing hospital operations and emergencies.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThere have been improvements if I were to compare myself to the past. Before RSLP I was unable to talk independently or connect with patients with empathy. RSLP has helped me in communicating with patients.\u0026rdquo; (RSLP Trainee)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBoth the current supervisors of the RSLP graduates seem happy with the amount of mentoring and supervision being given by the graduates to their junior doctors, one supervisor stated:\u003c/p\u003e\u003cp\u003eI would say I am positive about him doing a good job in that regard. When it comes to supervising a junior, teaching them something, and addressing any problems they bring to him, he is doing well.\u003c/p\u003e\u003cp\u003eThe graduates have so far managed to train the healthcare workers in CPR, post-operation management, and have taught junior doctors about wound care in their respective facilities. One supervisor stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003eHe has played a major role in improving the skills of the staff. He does lectures on surgical and non-surgical topics such as dosages of medications. He has conducted hands on CPR practices and created code scenarios to simulate\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eFurthermore, one of the RSLP graduates has actively taken initiative to make healthcare more affordable and accessible in the rural area he serves in. He shared:\u003c/p\u003e\u003cp\u003eI had to see ways to finance that and create awareness. It takes time because a change in mindset was required, building trust in the community for your surgical skills takes time.\u003c/p\u003e\u003cp\u003eFinally, RSLP graduates have forged strong partnerships with local government and healthcare leaders. These partnerships involve collaborating with existing healthcare leaders in the community and the government in their local areas to enhance healthcare services. Additionally, graduates have actively engaged with the community to address healthcare-related issues and improve overall well-being.2\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eForming partnerships with the government and collaborating with other healthcare providers after collaborating is also crucial for forming a system where surgical care can be provided in rural settings.\u0026rdquo; (RSLP graduate)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSpeaking about how a RSLP graduate brought his vision to life through different collaboration, his supervisor stated:\u003c/p\u003e\u003cp\u003eThe main challenge was financing the surgeries, bringing it within the reach of patients to avail. [RSLP graduate] developed and discussed models with the finance team, in which the fee surgeons\u0026rsquo; fees were minimal, and the hospital would not go into loss for each procedure.\u003c/p\u003e\u003cp\u003e Through visionary leadership, clinical excellence, and collaborative governance, these RSLP graduates not only revived surgical services in their rural posts but also established a self-sustaining, community-centered model of care.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRural surgical programs are essential for addressing the healthcare needs of rural communities, which often face a shortage of medical professionals, including surgeons (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This qualitative evaluation of the Rural Surgical Leadership Program (RSLP) highlights its role in addressing surgical inequities in rural Pakistan through workforce development, skill enhancement, and systemic reform. Key findings reveal that rural healthcare facilities face entrenched barriers\u0026mdash;geographic isolation, financial constraints, critical shortages of trained surgeons, and inadequate diagnostic and surgical equipment\u0026mdash;which collectively undermine surgical capacity and readiness. The findings align with global literature on rural healthcare in low and middleincome countries (LMICs), where geographic isolation, workforce shortages, and infrastructural deficits disproportionately affect surgical access (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The RSLP successfully equipped graduates with multidisciplinary procedural skills\u0026mdash;spanning obstetrics, trauma, orthopedics, and anesthesia\u0026mdash;enabling them to perform essential surgeries and reduce patient referrals to urban centers by 50\u0026ndash;60%. However, gaps persisted in orthopedic and radiological training, signaling opportunities for curricular refinement. Beyond technical competence, graduates demonstrated transformative leadership by revitalizing rural facilities through staff mentorship, operational restructuring, and community engagement, while collaborating with local governments to improve care affordability and accessibility. Our study findings align with and reinforce the Lancet Commission on Global Surgery\u0026rsquo;s call to integrate surgical care into national health systems as a cornerstone of universal health coverage (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eComparable international initiatives have likewise improved rural surgical capacity. For example, in Malawi, the COSTAfrica program trained clinical officers via a 36month curriculum\u0026mdash;yielding a 74% increase in district major surgeries, a rise from 31.3\u0026ndash;61.2% of general cases performed by trained officers, postoperative wound infections of 2.3% versus 8%, and zero surgical deaths across 5,590 procedures(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Furthermore, in New Zealand, Ashburton Hospital\u0026rsquo;s shift to a rural generalist model reduced senior surgeon fulltime equivalents by 40%, increased resident medical staff by 60%, doubled acute assessment presentations, boosted highacuity cases by 152%, and cut acute length of stay by 18% despite a 62% rise in tertiary admissions (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In Australia, their Remote Vocational Training Scheme achieved high retention among rural generalists, enhanced professional confidence, and improved competence through distance mentorship and peer networking (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eReflecting these models, the RSLP\u0026rsquo;s yearlong blended approach\u0026mdash;four months of competencybased urban tertiary training followed by supervised rural placement\u0026mdash;ensured surgeons developed both technical proficiency and contextual understanding before deployment. Graduates reported a 50\u0026ndash;60% reduction in referrals to urban centers, mirroring the 35% increase in district surgeries seen in COSTAfrica (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and the enhanced retention reported by RVTS alumni (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). By enabling onsite delivery of highpriority DCP-3 interventions, the RSLP alleviated patient travel costs and reduced morbidity from delayed care, demonstrating the impact of contextspecific training on service continuity.\u003c/p\u003e\u003cp\u003eBeyond surgical skills, the RSLP integrated graduatelevel leadership coursework that empowered surgeons to lead capacitybuilding workshops, optimize supply chains, and mentor junior staff\u0026mdash;interventions aligned with the World Health Organization\u0026rsquo;s health system building blocks for service delivery, workforce, and governance (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These reforms fostered local ownership of surgical services, strengthened interdepartmental collaboration, and secured sustainable financing through government partnerships. Similar Canadian global surgery partnerships have underscored the value of leadership training within clinical curricula to promote program sustainability and policy advocacy (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite these successes, participants identified deficiencies in orthopedics and radiology exposure\u0026mdash;skills that typically require extensive practice to master. Simulation-based orthopedic interventions\u0026mdash;such as low-cost phantom models for fracture stabilization (30% fewer procedural errors), pediatric fracture simulators, and modular workshops with locally manufacturable devices (25% faster assembly)\u0026mdash;paired with digital platforms like the IGOT Learning Portal, have enhanced technical proficiency (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In radiology, gelatin-based ultrasound phantoms, which have improved needle accuracy by 50%, tele-imaging systems, which have accelerated diagnosis times by 60%, and teleradiology workshops, which have enhanced interpretation accuracy by 45%, showcase how cost-effective, context-adapted tools and digital solutions address training gaps. (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo optimize the RSLP model, we recommend extending specialty rotations in orthopedics and radiology with integrated lowcost simulation (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e); formalizing telehealth integration for continuous mentorship and case review (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e); aligning the curriculum with global surgery competencies and WHO core indicators for standardized evaluation (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e); augmenting leadership modules with training in health financing, advocacy, and stakeholder engagement (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e); and partnering with ministries of health to embed rural surgical training within national budgets and explore slidingscale fee models to ensure affordability and sustainability. Telemedicine platforms in LMICs have supported postoperative followup, remote case consultations, and multidisciplinary discussions\u0026mdash;reducing isolation and improving outcomes (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). More structured tele mentoring interventions, evaluated in AOS Open, demonstrated moderate to strong evidence for enhancing surgical knowledge and competence among practicing surgeons, positively influencing decisionmaking and technical performance (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe Rural Surgical Leadership Program (RSLP) combines context-specific, competency-based surgical training with leadership development, simulation, telehealth and rigorous evaluation to address rural workforce shortages and systemic inequities in low-resource settings. Its graduates\u0026mdash;proficient across obstetrics, trauma and multidisciplinary care\u0026mdash;have cut urban referrals by over 50% while highlighting persistent gaps in orthopedics and radiology that demand enhanced simulation and telehealth tools. By aligning with WHO surgical indicators and Lancet Commission targets, forging government and community partnerships and implementing subsidized surgical models, the RSLP offers a scalable, affordable blueprint for strengthening rural surgical capacity and advancing universal access to safe, timely and affordable surgery in LMICs. Sustained investment in such blended training models is essential to close the procedure gap and reduce the economic and mortality burdens of unmet surgical needs.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAKU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAga Khan University\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPSP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCollege of Physicians and Surgeons of Pakistan\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDCP-3\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDisease Control Priorities, 3rd Edition\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Room\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDIs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn-depth Interviews\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKIIs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKey Informant Interviews\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBBS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBachelor of Medicine, Bachelor of Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOperating Room\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRAs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eResearch Associates\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eResearch Coordinator\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRSLP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRural Surgical Leadership Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethical Review Committee of the Aga Khan University (Reference #: 2024-10448-30996) and conducted in accordance with the principles of the Declaration of Helsinki. Verbal informed consent was obtained from all five interviewees prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe have consent for publication from all the listed authors and the interviewees.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during this study are presented in Table 1 of Appendix 1. They were coded and analyzed. The questionnaires administered to trainees and their employers are also provided in the appendix section. All data were derived exclusively from interviews conducted by the research team at Aga Khan University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sharjeel Ahmad, Mohammad Kumael Azhar, and Muhammad Uzair: Conceptualized the study, drafted the manuscript, and contributed to critical revisions.\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sadaf Khan, Saleema Begum, and Zeeshan Nasir Rifat: Designed and implemented the RSLP program.\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sharjeel Ahmad, Sadaf Khan, Saleema Begum, and Zeeshan Nasir Rifat: Developed the interview guide, conducted interviews, and performed data validation.\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bilal Ahmed Lodhi and Sofia Chugtai: Transcribed interviews and contributed to the methodology section.\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Syed Mahnoor Shah: Performed qualitative data analysis and constructed the results table.\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sharjeel Ahmad: Designed and prepared the study figure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to the RSLP participants and their employers.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Medical Association Declaration of Helsinki. JAMA. 2013 Nov 27;310(20):2191.\u003c/li\u003e\n\u003cli\u003eMeara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. The Lancet [Internet]. 2015 Aug 8 [cited 2024 May 16];386(9993):569\u0026ndash;624. Available from: http://www.thelancet.com/article/S014067361560160X/fulltext\u003c/li\u003e\n\u003cli\u003eAwuah WA, Adebusoye FT, Ferreira T, Azeem S, Bharadwaj HR, Akpan AA, et al. The unmet surgical needs of global refugee populations: A perspective review. SAGE Open Med [Internet]. 2023 Jan 1 [cited 2024 May 16];11. Available from: /pmc/articles/PMC10566266/\u003c/li\u003e\n\u003cli\u003eBickler SW, Weiser TG, Kassebaum N, Higashi H, Chang DC, Barendregt JJ, et al. Global Burden of Surgical Conditions. Disease Control Priorities, Third Edition (Volume 1): Essential Surgery [Internet]. 2015 Mar 23 [cited 2024 May 16];19\u0026ndash;40. Available from: https://pubmed.ncbi.nlm.nih.gov/26741011/\u003c/li\u003e\n\u003cli\u003ePakistan Rural population, percent - data, chart | TheGlobalEconomy.com [Internet]. [cited 2024 May 16]. Available from: https://www.theglobaleconomy.com/Pakistan/rural_population_percent/\u003c/li\u003e\n\u003cli\u003eAhmed M, Raja A, Nundy S. Surgery in South Asia. Br Med J. 2004 Apr 3;328(7443):782.\u003c/li\u003e\n\u003cli\u003eOfficial Launch of Pakistan\u0026rsquo;s Surgical Plan \u0026mdash; The Global Surgery Foundation [Internet]. [cited 2024 May 16]. Available from: https://www.globalsurgeryfoundation.org/events/pakistan-2020-25\u003c/li\u003e\n\u003cli\u003eM. M. Shah1 MAZNRSK 1Aga KUKSPakistan https://www. asc abstracts. org/abs2024/66 04 rural surgery leadership program from a blueprint to reality/. 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Surgical Clinics of North America. 2020 Oct;100(5):869\u0026ndash;77.\u003c/li\u003e\n\u003cli\u003eMeara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015 Aug;386(9993):569\u0026ndash;624.\u003c/li\u003e\n\u003cli\u003eHuda MdD, Rahman M, Mostofa MdG, Sarkar P, Islam MdJ, Adam IF, et al. Health Facilities Readiness and Determinants to Manage Cardiovascular Disease in Afghanistan, Bangladesh, and Nepal: Evidence from the National Service Provision Assessment Survey. Glob Heart. 2024 Mar 20;19(1):31.\u003c/li\u003e\n\u003cli\u003eGajewski J, Borgstein E, Bijlmakers L, Mwapasa G, Aljohani Z, Pittalis C, et al. Evaluation of a surgical training programme for clinical officers in Malawi. British Journal of Surgery. 2019 Jan 8;106(2):e156\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eWithington S, Kiuru S, Wilson S, Lyons J, Feberwee A, Lander J. Transition of the medical model of care at Ashburton hospital over 10 years: the perspective of rural generalists. N Z Med J. 2020 Apr 3;133(1512):67\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Sullivan BG, Giddings P, Gurney R, McGrail MR, Gurney T. Holistic support framework for doctors training as rural and remote general practitioners: a realist evaluation of the \u0026lt;scp\u0026gt;RVTS\u0026lt;/scp\u0026gt; model. Medical Journal of Australia. 2024 Oct 7;221(S7).\u003c/li\u003e\n\u003cli\u003eManyazewal T. Using the World Health Organization health system building blocks through survey of healthcare professionals to determine the performance of public healthcare facilities. Archives of Public Health. 2017 Dec 31;75(1):50.\u003c/li\u003e\n\u003cli\u003eKhalid MU, Mac A, Biderman M, Errett L, Sriharan A. Partnering to build surgical capacity in low-resource settings: a qualitative study of Canadian global surgeons. BMJ Open. 2023 Mar 22;13(3):e070148.\u003c/li\u003e\n\u003cli\u003eUrwin JW, Trionfo A, Storey EP, Brusalis CM, Gajewski C, Lawrence JTR. A Novel Low-Cost Surgical Simulation Tool for Pinning Supracondylar Humerus Fractures. Journal of Pediatric Orthopaedics. 2020 May;40(5):e317\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eSONI J, GAMBA LK, BEBBER FDS, KOZOVITS F. DEVELOPMENT OF ORTHOPEDIC SIMULATOR TO PRACTICE CLOSED REDUCTION OF PEDIATRIC FRACTURES OF THE MIDDLE THIRD OF FOREARM. Acta Ortop Bras. 2023;31(1).\u003c/li\u003e\n\u003cli\u003eSaeidi M, Barnes SC, Berthaume MA, Holthof SR, Milandri GS, Bull AMJ, et al. Low-cost locally manufacturable unilateral imperial external fixator for low- and middle-income countries. Front Med Technol. 2022 Nov 28;4.\u003c/li\u003e\n\u003cli\u003eBrown KE, Flores MJ, MacKechnie MC, Rodarte P, O\u0026rsquo;Marr J, Shearer DW, et al. Novel e-learning platform for orthopaedic training in LMICs: A descriptive review of the IGOT portal. Surg Open Sci. 2023 Jun;13:24\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGiannotti E, Jethwa K, Closs S, Sun R, Bhatti H, James J, et al. Promoting simulation-based training in radiology: a homemade phantom for the practice of ultrasound-guided procedures. Br J Radiol. 2022 Sep 1;95(1137).\u003c/li\u003e\n\u003cli\u003eAdambounou K, Adjenou V, Salam AP, Farin F, N\u0026acirc;\u0026euro;\u003csup\u003eTM\u003c/sup\u003eDakena KG, Gbeassor M, et al. A Low-Cost Tele-Imaging Platform for Developing Countries. Front Public Health. 2014 Sep 5;2.\u003c/li\u003e\n\u003cli\u003eNortey JNN, Agbotsigah LA, Osei EO, Adabo A, Gborgblah M, Suleiman R. Review of Teleradiology Applications in Some Selected African Countries. 2023.\u003c/li\u003e\n\u003cli\u003eIrfanullah EA, Chandra A, Solaiman RH, Siems C, Chethan S, Belani K, et al. Simulation Training in a Lower Middle-Income Country: Supporting a New Center and Developing Low-Cost Models for Critical Skill Acquisition. Cureus. 2023 Jun 25;\u003c/li\u003e\n\u003cli\u003eOwolabi EO, Mac Quene T, Louw J, Davies JI, Chu KM. Telemedicine in Surgical Care in Low‐ and Middle‐Income Countries: A Scoping Review. World J Surg. 2022 Aug 15;46(8):1855\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003eFernandes R Del, Ghasroddashti A, Sorefan-Mangou F, Williams E, Choi K, Fasola L, et al. Educational Effectiveness of Telementoring as a Continuing Professional Development Intervention for Surgeons in Practice: A Systematic Review. Annals of Surgery Open. 2023 Dec;4(4):e341.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Flynn E, Danial A, Gajewski J. Global Surgery Education and Training Programmes\u0026mdash;a Scoping Review and Taxonomy. Indian Journal of Surgery. 2022 Apr 25;84(S1):193\u0026ndash;206.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rural Surgical Leadership Program, Global Surgery, Surgical Training, Rural Healthcare, LMICs, Workforce Development","lastPublishedDoi":"10.21203/rs.3.rs-6583649/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6583649/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGlobally, 5\u0026nbsp;billion individuals lack access to safe surgical care, with rural regions in low- and middle-income countries (LMICs) disproportionately affected. In Pakistan, rural areas face critical surgical workforce shortages (6 specialists/100,000 people) and infrastructural deficits, compounded by financial barriers. The Rural Surgical Leadership Program (RSLP) was designed to train general surgeons in multidisciplinary procedural and leadership skills to address these gaps.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative case study evaluated the RSLP through semi-structured interviews (n = 5: 3 graduates, 2 supervisors) conducted via telephone (September–October 2024). Transcripts were thematically analyzed with inductive coding, supported by reflexivity and peer debriefing to ensure rigor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree themes emerged: (1) Rural facilities faced systemic challenges, including geographic isolation, absent surgical staff, and inadequate equipment. (2) RSLP graduates gained proficiency in obstetrics and trauma care but reported gaps in orthopedics and radiology. (3) Graduates demonstrated leadership, reducing urban referrals by 50–60%, mentoring staff, and optimizing workflows. Supervisors noted their impact exceeded clinical care, including community outreach and affordability initiatives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSummary and Conclusion\u003cbr\u003e\n \u003c/strong\u003eThe RSLP highlights the transformative potential of context-adapted surgical training in LMICs. Graduates’ ability to reduce referrals and revitalize rural services aligns with global models like Malawi’s COST-Africa and Australia’s Remote Vocational Training Scheme. Persistent gaps in orthopedics and radiology underscore the need for integrated simulation tools (e.g., low-cost phantoms) and telehealth for continuous mentorship. Policy recommendations include extending specialty rotations, formalizing telemedicine partnerships, and aligning curricula with WHO surgical indicators. By merging technical and leadership training, the RSLP provides a replicable framework to strengthen rural surgical systems. Sustained investment in such programs is critical to advancing equitable access to essential surgery and achieving universal health coverage in underserved regions.\u003c/p\u003e","manuscriptTitle":"Cultivating Rural Surgical Leaders: Insights from a Qualitative Case Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 09:23:21","doi":"10.21203/rs.3.rs-6583649/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-22T07:49:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-15T11:34:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-14T16:20:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62726466095599835703022574392210124175","date":"2025-07-10T10:15:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-04T01:19:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-03T03:07:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92347109487230909514222940243136504871","date":"2025-06-26T19:33:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22084287046186565625456818254530934305","date":"2025-06-24T22:44:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204800946782831030822828441134693933561","date":"2025-06-24T20:00:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T18:40:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-18T07:54:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-23T10:29:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-09T14:50:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-09T14:49:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f241bfd0-38b2-497e-87e3-e1adb880b44e","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:00:18+00:00","versionOfRecord":{"articleIdentity":"rs-6583649","link":"https://doi.org/10.1186/s12913-026-14640-w","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-04-28 15:57:36","publishedOnDateReadable":"April 28th, 2026"},"versionCreatedAt":"2025-07-02 09:23:21","video":"","vorDoi":"10.1186/s12913-026-14640-w","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14640-w","workflowStages":[]},"version":"v1","identity":"rs-6583649","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6583649","identity":"rs-6583649","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}