Cultivating rural surgical leaders through a structured training program: a qualitative case study

Globally, 5 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. This study aimed to explore the feasibility and perceived impact of a context-adapted surgical leadership program designed to meet rural health system needs in Pakistan.

This embedded qualitative single 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.

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. 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. 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.