Expanding Cleft Surgical Workforce Capacity in Low- and Middle-Income Countries Through Competency-Based Training

ObjectiveTo evaluate a competency-based cleft surgery training pathway designed to expand local surgical capacity in low- and middle-income countries (LMICs).DesignProspective observational study of cleft surgery training outcomes between July 2022 and September 2024.SettingOperation Smile cleft surgery programs and partner hospitals in LMICs, with integrated virtual education.Patients/ParticipantsTwenty trainee cleft surgeons from 11 countries.InterventionsA competency-based training pathway combining virtual education and mentored operative experience, with assessment using a validated surgical competency tool.Main Outcome MeasuresChanges in self-reported surgical confidence and educator-rated surgical competencyResultsTrainee cleft surgeons participated in 1168 cleft lip and palate repairs, including 862 primary procedures. Confidence improved significantly for all primary procedures (unilateral cleft lip (UCL) P = .001; bilateral cleft lip P < .001; cleft palate P < .001), with greatest gains in cleft palate repair. Educator-rated competency increased by 46% for UCL, 56% for bilateral cleft lip, and 71% for cleft palate repair. By September 2024, 3 surgeons had completed the pathway; by April 2025, 8 had completed training, with others progressing toward certification.ConclusionsCompetency-based cleft surgery training in LMICs, delivered through partnerships between non-governmental organizations and local health systems, improves surgical confidence and competence while maintaining local workforce integration. Combining high-volume operative experience with structured education offers a scalable model to expand workforce capacity and support sustainable, locally led cleft care. Long-term success depends on developing systems capable of sustaining training and service delivery independently.