GSPU Research and Education
Research
The GSPU staff conduct research across a number of areas, illustrated by the current list of projects.
This was GSPU’s first project. Led by MD student and military surgical registrar, Gerard McKnight, a Delphi Consensus was performed which has, for the first time, defined Humanitarian Surgery as a distinct branch of Global Surgery. Published in the British Journal of Surgery and gaining acceptance in the surgical community and with humanitarian organisations, this definition will provide clarity around various medical missions, form the basis of future research and allow objective comparisons of different programs and funding models.
Link: Defining humanitarian surgery: international consensus in global surgery | BJS | Oxford Academic
The first large grant awarded to GSPU in 2022 was from ELRHA to fund the SPACES ECHO project (Somaliland Paediatric Access & Clinical Excellence in Surgery). This project aimed to assess whether surgical care for children with burns and pyloric stenosis can be strengthened by adoption of the Expanding Community Healthcare Outcomes (ECHO) models for sustainable community-based tele-learning, knowledge transfer and exchange. The model was used to improve the knowledge and skills of non-surgically trained healthcare staff, thereby improving clinical outcomes.
Most of the sessions were led by surgeons and academics from Somaliland, with oversight from Dr Tihitina Negussie (paediatric surgeon, Black Lion Hospital, Addis Ababa) and Miss Hargest.
In September 2024, a closing ceremony was held in Hargeisa, Somaliland, attended by the minister of health and director general of the Ministry of Health Development (MOHD). The first Somaliland surgical research conference was held during this meeting and demonstrated the capacity building in surgical research and engagement which has resulted from this project. The visit also included the opening of the new Children’s Hospital in Hargeisa by the former president and meetings of the GSPU’s co-directors with the minister and MOH senior staff. Financial contributions from SPACES-ECHO supported the development of Somaliland’s first National Surgical Obstetrics and Anaesthesia Plan.
In collaboration with the Universities of Oxford, Harare and Tanzania, this 4-year project has been funded by a grant of £2.9m from the National Institute for Health Research (NIHR) to study the epidemiology, prevention and treatment of childhood injuries in Tanzania and Zimbabwe. The project also aims to build academic and research capacity in the collaborating African university departments of surgery and includes provision for four surgeons to undertake PhD theses under the joint supervision of local professors of surgery and collaborators in Oxford and GSPU. This project has a significant input from community groups and charities involved with road safety and accident prevention and involves liaison with the local ministries of health and transport.
In collaboration with the Department of Neurosurgery at Cambridge University and the Society of British Neurosurgeons (SBNS), the GSPU is working to determine the cost of treating head injuries in different health systems. Head trauma leads to significant morbidity and mortality despite maximal interventions, with significant burden of care seen in low and middle income countries. Under the supervision of Professor Peter Hutchinson, Dr Swati Jain (neurosurgeon and PhD student in Cambridge) is working with the GSPU to itemise and cost all elements of pre-hospital, in-hospital and rehabilitation care of patients with head injury. This important study links with Prof Hutchinson’s previous development of the international GEO-TBI database which aims to record all patients with traumatic brain injury (TBI) internationally which will allow comparison of causation, treatment and outcomes along with the cost effectiveness of different systems of providing care to head injury.
One of the problems which besets global surgery is that despite the huge number of short-term courses and educational initiatives which are undertaken by various surgical societies and charities, very few have led to sustainable improvements in surgical training in low-and middle-income countries (LMICs). One of the main reasons for this is that most of these courses have been designed by and for surgeons practising in high income countries and may not address the training requirements of surgeons practising in LMICs. In order to address this issue, Humanitarian Surgery Initiative Innovation Fellow Gerard McKnight undertook a robust Training Needs Analysis for surgical and anaesthetic providers in Somaliland and South Africa. There was excellent engagement from surgical associations in both countries and the World Federation of Societies of Anaesthesiology. This work has been awarded an MD by Cardiff University.
A novel Training Needs Analysis of surgical teams in Somaliland, https://doi.org/10.1093/bjs/znaf216
The topic of task shifting in surgery has proved controversial in the UK due to debate over the training, scope of practice and regulation of physician associates (PAs). However, in many LMICs, where trained surgeons are in desperately short supply, much surgical work is carried out by non-medical practitioners who undertake various forms of basic surgery. A literature of worldwide experience of task shifting in surgery and anaesthesia was conducted leading to the award of an MSc to Maeve Bognini and a publication in Health Policy and Planning. Subsequent work in this area led to the GSPU leading a policy dialogue on the role of non-medical surgical providers, with the Ethiopian Ministry of Health, the African Health Observatory and the WHO in Addis Ababa in December 2023 and the recommendations have been published.
A Policial Economy Analysis of Ethiopia’s Integrated Emergency Surgical Officers Programme https://doi.org/10.1093/bjs/znaf220
Many surgeons and surgical organisations based in the global north undertake humanitarian missions to LMICs, particular to areas of conflict or natural disaster. There is a general assumption that these missions are of great value but the voices of the local surgeons who are working in these difficult areas before and after the international team has been and gone are rarely heard. Identifying such surgeons, particularly in dangerous areas of conflict, is difficult. Dr Isobel Marks, HSI fellow, undertook a series of structured interviews with surgeons from the Middle East and North Africa who had worked throughout periods of ongoing conflict. There is much that can be learned from their experience. Their views of incoming surgical teams, although broadly positive, raised issues which should be addressed by teams proposing to provide humanitarian surgery support. The results of this project are being reported in a forthcoming manuscript.
"Everyone wants to be a hero" Qualitative perspectives on incoming medical teams during conflict from surgeons in the Middle East and North Africa https://doi.org/10.1093/bjs/znaf209
The cost of providing surgical care is substantial, even for a basic service. However, the LCOGS made clear that investment in surgical care should be an integral part of universal healthcare (UHC) packages. In order to facilitate this, countries were encouraged to develop National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) and to budget accordingly. Nigeria has introduced a sugar tax which is hypothecated for the development of its NSOAP. Dr Ifeanyichi has worked with colleagues in Nigeria to perform a mixed methods political economy analysis to determine the extent to which the ‘sugar tax’ can be leveraged to finance the implementation of Nigeria’s NSOAP. This work was published in Health Policy and Planning in 2024.
Dr Tiencheu and Dr Ryan-Coker, under supervision of Miss Hargest, assessed the cost to the individual surgeon of surgical training in Africa, to estimate the true costs of providing paediatric surgical services and to compare the value of undertaking short term surgical missions compared with investment in local surgical services. Details are given in Table 1. The GSPU has also been commissioned by the WHO to provide evidence for the assessment and monitoring of the ECO (Emergency Critical and Operative Care) resolution WHA76.2.
This was a systematic review to assess critical research gaps in the field of global surgery guided by the World Health Organisation’s health system building block framework, analysis of authorship and funding patterns and an exploration of emerging research partnership networks. This paper was published in the BMC Health Services Research in September 2023.
This project, commissioned by the Global Initiative for Children’s Surgery, concluded that capital investments are required to equip first level hospitals in LMICs to provide children’s surgical care. While the upfront costs may be substantial, they are fiscally achievable and sustainable with significant economic and social return on investment. These cost estimates provide a reference case to guide investments to improve surgical care for children.
A systematic review and critical analysis of recent evidence to assess the cost-effectiveness of surgical interventions. This was published in BMJ Global Health in October 2024.
The GSPU was commissioned by the World Health Organisation (WHO) via RCS England to support the implementation of the World Health Assembly adopted resolution WHA76.2 on Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies (the ECO resolution).
The resolution calls on the WHO to develop guidance for Member States on emergency, critical and operative care (ECO) monitoring and to provide data and information to be used in the development of ECO services.
The GSPU has been commissioned to conduct a scoping review of emergency, critical and operative care (ECO) assessment at national and subnational levels; and carry out key informant interviews on the status of national and subnational ECO systems. Key outcomes of this work will include the development of indicators and the collation of evidence for the development of a WHO toolkit.
Economic Value of International Missions and Domestic Initiatives to Strengthen Surgical Care in Low- and Middle-Income Countries: A Systematic Review https://doi.org/10.1093/bjs/znaf207
Education
The GSPU staff regularly undertake lecturing, teaching and supervising of both students and health care workers. Every year Masters students from LSE undertake their dissertations in collaboration with the GSPU. A Masters student from Uppsala University joined the unit in the summer of 2025. Thus far one student has been awarded an MD and two are undertaking a PhD.
Surgical training needs in low resource settings – can technology assist in delivering sustainable improvements?
Doctoral student: Gerard McKnight, Cardiff University; MD awarded 2024
Global Burden of Surgical Disease
Doctoral student: Sabrina Wimmer, LSE; PhD (in progress)
Cost of treating head injuries
Doctoral student: Swati Jain, Cambridge University; PhD (in progress)
Factors influencing delayed presentation of breast cancer in South Africa
MSc Student: Yannis Reissis (2024 – 2025)
Measuring the opportunity cost of surgical care of injuries
MSc Student: Yaoding Chen (2022 – 2023)
Mismatch of Surgery in Humanitarian Settings
MSc Student: Shreeja Sarabu (2022 – 2023)
Global Surgery Attrition rates during training
MSc Student: Emmanuella Adu-Peprah (2022 – 2023)
A comparison of the development and design of NSOAPs in low & middle-income countries
MSc Student: Alshaheed Abdelhabeeb (2022 – 2023)
Humanitarian capital migration in low & middle-income countries
MSc Student: Aanchal Thadani (2022 – 2023)
Burn injuries and austerity
MSc Student: Sonia Ike (2022 – 2023)
Task shifting in Surgery and Anaesthesia
MSc Student: Maeve Bognini (2021 – 2022)
Measuring patient acceptability of task shifting and sharing in Global Surgery: A global delphi survey
MSc Student: Avneet Bhullar (2021 – 2022)
Partnerships with Institutions
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GSPU have commenced a partnership with Einstein University in Sao Paolo, Brazil. Two fellows have been appointed to work with GSPU for a year to undertake a research project whilst learning about research methodology in health economics, health policy and health service management. Dr Felipe Delpino and Dr Francisco Tustumi attended an immersion week at RCSEng and LSE during February 2025 and will be attached to GSPU for a year. The project aims to improve health systems in Sao Paolo and to utilize the large database of patient information which exists but which they currently are unable to utilize to generate useful outcomes.
Dr Tustumi is currently working on a project titled Public-Private Partnerships in Brazil and Their Role in the Diffusion of Minimally Invasive Surgery. This project discusses the challenges faced by Brazil’s Unified Health System and aims to ascertain the rate of uptake of laparoscopic surgery within the Social Health Organisations (SHO) network of hospitals, compared to other facilities.
Dr Delpino’s project focusses on whether the SHO hospitals have improved cancer care for patients in Brazil. He aims to establish whether SHO hospitals are providing more efficient diagnostic and management pathways, using examples from breast, prostate and colon cancer.
During 2025, the GSPU has partnered with Havard Medical School on a series of webinars entitled “A Comprehensive Approach to Financing Global Surgical Care”. Dr Ifeanyichi will be one of the invited lecturers for this series.