A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania

  • Augustino HellarEmail author
  • Leopold Tibyehabwa
  • Edwin Ernest
  • John Varallo
  • Margaret Mary Betram
  • Laura Fitzgerald
  • Geofrey Giiti
  • Albert Kihundrwa
  • Ntuli Kapologwe
  • Mary Drake
  • Jeremie Zoungrana
  • Alena Troxel
  • Ruth Lemwayi
  • Shehnaz Alidina
  • Sarah Maongezi
  • Ahmad Makuwani
  • John Varallo
Surgery in Low and Middle Income Countries



Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates.


We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018.


During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p < 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p < 0.05).

Conclusion and recommendations

Our findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania’s National Surgical, Obstetric, and Anesthesia Plan (NSOAP).



Cesarean section


Faith-based organization


National surgical, obstetric, and anesthesia plan


Operating room


Operating theater


World Health Organization


Regional/Council Health Management Team


Surgical safety checklist



Safe Surgery 2020 is a unique multi-stakeholder partnership that transforms surgical systems through an ecosystem approach, implemented by Jhpiego, Dalberg, Assist International, Harvard Program on Global Surgery and Social Change (PGSSC), and other stakeholders in surgery, obstetric and anesthesia care. The work presented here involves the commitment and dedication of a multitude of health care workers including facility managers, surgical providers, anesthetists and nurses, as well as district and regional authorities in Kagera and Mara regions. We are grateful for the leadership and collaboration from the Ministry of Health Community Development Gender Elderly and Children and Presidents’ Office Regional Authorities and Local Governments. Adrienne Kols, Sharon Kibwana, Young-Mi Kim, Adam Katoto, Stella Mshana, and Dr Tigistu Adamu Ashengo are acknowledged immensely for their contribution to this work.

Authors’ contribution

AH, LT, and EE drafted the manuscript. EE managed the data, ran reports, and analyzed the data. JV, MB, LF, SM, GG, AK, NK, MD, JZ, AT, SA, RL, and AM provided inputs on the discussion and overall write-up. All authors read and reviewed the drafts of the manuscript.


This project was funded under grant number 5R18HS024235-02 from the GE Foundation and Grant Number 17-F0012 from ELMA Philanthropies. The contents are the responsibility of the authors and do not necessarily reflect the views of the GE Foundation or ELMA. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Augustino Hellar
    • 1
    Email author
  • Leopold Tibyehabwa
    • 1
  • Edwin Ernest
    • 1
  • John Varallo
    • 2
  • Margaret Mary Betram
    • 2
  • Laura Fitzgerald
    • 2
  • Geofrey Giiti
    • 3
  • Albert Kihundrwa
    • 4
  • Ntuli Kapologwe
    • 5
  • Mary Drake
    • 1
  • Jeremie Zoungrana
    • 1
  • Alena Troxel
    • 2
  • Ruth Lemwayi
    • 1
  • Shehnaz Alidina
    • 6
  • Sarah Maongezi
    • 7
  • Ahmad Makuwani
    • 7
  • John Varallo
    • 2
  1. 1.Jhpiego TanzaniaDar-es-SalaamTanzania
  2. 2.JhpiegoBaltimoreUSA
  3. 3.Department of SurgeryCatholic University of Health and Allied Sciences, Weill-BugandoMwanzaTanzania
  4. 4.Department of Obstetrics and GynaecologyBugando Medical CenterMwanzaTanzania
  5. 5.President’s Office Regional Authority and Local GovernmentDodomaTanzania
  6. 6.Program in Global Surgery and Social ChangeHarvard Medical SchoolBostonUSA
  7. 7.Ministry of Health Community Development, Gender, Elderly and ChildrenDodomaTanzania

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