The impact of surgical task-sharing in Sierra Leone: a nationwide longitudinal observational study on surgical workforce and volume, 2012–2023

Background A surgical task-sharing programme was initiated by the Sierra Leonean Ministry of Health in 2011 to enhance public surgical capacity and equalise access between urban and rural populations by redistributing surgical tasks within a limited healthcare workforce. Methods This longitudinal nationwide study, involving all healthcare facilities with an operating theatre in Sierra Leone, analysed changes in volume and population rates of surgery and distribution of surgical resources before (2012), 5 (2017) and 10 years after (2023) the initiative was introduced. Results Surgical volume rates increased from 400 to 505 procedures per 100 000 population between 2012 and 2023. The public sector became the main provider, performing 56.0% of all operations in 2023, up from 39.6% in 2012. Rural surgeries increased by 77.6% over the decade, almost two times more than in urban areas. In rural areas, there was a transition from non-specialised physicians performing 46.2% of operations in 2012, to task-shared associate clinicians performing 55.1% (95% CI 49.5% to 60.7%) in 2023, making them the main surgical provider. Nationwide caesarean section rates increased from 1.4% (2012) to 5.3% (95% CI 4.6% to 6.0%) (2023). Caesarean sections were in 2023 mostly performed in public facilities (81.3%, 95% CI 80.1.0% to 82.5%) by associate clinicians (57.6%, 95% CI 53.2% to 61.9%). Conclusions Over the last decade, Sierra Leone has seen a shift in surgical care, with a transition from general to obstetric surgeries, from private to public institutions, and an expansion of surgical care in rural areas, with associate clinicians as the leading provider. The introduction of a nationwide surgical task-sharing initiative to strengthen the surgical workforce at district governmental hospitals in 2011 has emerged as the major contributor to the change in surgical activity and output observed in Sierra Leone over the last decade.