Skip to main content

Systematic Review of Postgraduate Surgical Education in Low- and Middle-Income Countries


Surgical care is recognized as an important component of public health, however, many low- and middle- income countries (LMICs) are faced with a shortage of trained personnel. In response to this unmet need, many countries have developed local postgraduate training programs in surgery. This study aims to characterize general surgery postgraduate education in LMICs. PubMed, EMBASE, and Global Index Medicus databases were searched for articles related to postgraduate general surgery education in LMICs. Studies in other surgical specialties and those published prior to 1990 were excluded. Data were collected on the characteristics of postgraduate training programs. Sixty-four articles discussed postgraduate surgical education in LMICs. Programs in 34 different countries and 6 different regions were represented. Nine countries were low-income, 12 were low-middle-income, and 13 were upper-middle-income countries. Sixty-four articles described aspects of the local postgraduate training program. Prior to postgraduate training, residents complete an undergraduate medical degree with 19 programs describing a pre-training experience such as internship. Surgical curricula were broad-based to prepare trainees to work in low-resource settings. At the completion of postgraduate training, examination formats varied including oral, written, and clinical exams. Postgraduate general surgery programs ranged from 2.5 to 7 years. Postgraduate surgical education is one mechanism to increase surgical capacity in LMICs. Different strategies have been employed to improve surgical education in LMICs and learning from these programs can optimize surgical education across teaching sites.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    Funk LM, Weiser TG, Berry WR et al (2010) Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 376:1055–1061

    Article  PubMed  Google Scholar 

  2. 2.

    Grimes CE, Law RSL, Borgstein ES, Mkandawire NC, Lavy CBD (2012) Systematic review of met and unmet need of surgical disease in rural sub-Saharan Africa. World J Surg 36:8–23. doi:10.1007/s00268-011-1330-1

    Article  PubMed  Google Scholar 

  3. 3.

    Higashi H, Barendregt JJ, Kassebaum NJ et al (2015) Surgically avertable burden of digestive diseases at first-level hospitals in low and middle-income regions. Surgery 157:411–419 discussion 420–412

    Article  PubMed  Google Scholar 

  4. 4.

    Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN (2015) Disease control priorities, 3rd edn. World Bank, Washington, DC

    Google Scholar 

  5. 5.

    McCord C, Chowdhury Q (2003) A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet 81:83–92

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Gosselin RA, Thind A, Bellardinelli A (2006) Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 30:505–511. doi:10.1007/s00268-005-0609-5

    Article  PubMed  Google Scholar 

  7. 7.

    Beard JH, Oresanya LB, Akoko L et al (2014) Surgical task-shifting in a low-resource setting: outcomes after major surgery performed by nonphysician clinicians in Tanzania. World J Surg 38:1398–1404. doi:10.1007/s00268-013-2446-2

    Article  PubMed  Google Scholar 

  8. 8.

    Cadotte DW, Blankstein M, Bekele A et al (2013) Establishing a surgical partnership between Addis Ababa, Ethiopia, and Toronto, Canada. Can J Surg 56:E19–23

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Khambaty FM, Ayas HM, Mezghebe HM (2010) Surgery in the Horn of Africa: a 1-year experience of an American-sponsored surgical residency in Eritrea. Arch Surg. 145:749–752

    Article  PubMed  Google Scholar 

  10. 10.

    Cameron BH, Rambaran M, Sharma DP et al (2010) International surgery: the development of postgraduate surgical training in Guyana. Can J Surg 53:11–16

    PubMed  PubMed Central  Google Scholar 

  11. 11.

    Singh P, Aggarwal R, Darzi A (2014) Review of selected national surgical curricula: quantity is not the sole marker of quality. J Surg Educ 71:229–240

    Article  PubMed  Google Scholar 

  12. 12.

    Moher D, Liberati A, Tetzlaff J, Douglas AG, The PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Open Med 3:123–130

    Google Scholar 

  13. 13.

    Country and Lending Groups: World Bank (2015).

  14. 14.

    Free Online OCR: Sciweavers LLC; (2015)

  15. 15.

    Global Health Observatory Data: World Health Organization (2015).

  16. 16.

    World Bank Indicators: World Bank (2015).

  17. 17.

    Drislane FW, Akpalu A, Wegdam HHJ et al (2014) Establishment of a general medicine residency training program in rural west Africa. Yale J Biol Med 87:327–339

    PubMed  PubMed Central  Google Scholar 

  18. 18.

    Newton M, Bird P (2010) Impact of parallel anesthesia and surgical provider training in sub-Saharan Africa: a model for a resource-poor setting. World J Surg 34:445–452. doi:10.1007/s00268-009-0195-z

    Article  PubMed  Google Scholar 

  19. 19.

    Mazwai EL (1997) Training surgically competent doctors for South African rural settings. S Afr J Surg 35:147–148

    CAS  PubMed  Google Scholar 

  20. 20.

    Apte NK, Kerkar PG, Steele G Jr et al (1994) Health care delivery system and surgical education in India. World J Surg 18:686–690. doi:10.1007/BF00298902

    Article  Google Scholar 

  21. 21.

    Galukande M, Ozgediz D, Elobu E et al (2013) Pretraining experience and structure of surgical training at a sub-Saharan African university. World J Surg 37:1836–1840. doi:10.1007/s00268-013-2053-2

    Article  PubMed  Google Scholar 

  22. 22.

    Elobu AE, Kintu A, Galukande M et al (2014) Evaluating international global health collaborations: perspectives from surgery and anesthesia trainees in Uganda. Surgery 155:585–592

    Article  PubMed  Google Scholar 

  23. 23.

    Lipnick M, Mijumbi C, Dubowitz G et al (2013) Surgery and anesthesia capacity-building in resource-poor settings: description of an ongoing academic partnership in Uganda. World J Surg 37:488–497. doi:10.1007/s00268-012-1848-x

    Article  PubMed  Google Scholar 

  24. 24.

    Magoha GA, Ngumi ZW (1999) Training of surgeons in Kenya at the University of Nairobi teaching hospital. East Afr Med J 76:462–464

    CAS  PubMed  Google Scholar 

  25. 25.

    Qureshi JS, Young S, Muyco AP et al (2013) Addressing Malawi’s surgical workforce crisis: a sustainable paradigm for training and collaboration in Africa. Surgery. 153:272–281

    Article  PubMed  Google Scholar 

  26. 26.

    Cameron B, Prashad J, Rambaran M (2014) Evaluating the outcomes of a surgical postgraduate training program in Guyana. Ann Global Health 80:157

    Article  Google Scholar 

  27. 27.

    Cameron BH, Martin C, Rambaran M (2015) Surgical training in Guyana: the next generation. Can J Surg 58:7–9

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Bode CO, Nwawolo CC, Giwa-Osagie OF (2008) Surgical education at the West African College of Surgeons. World J Surg 32:2162–2166. doi:10.1007/s00268-008-9710-x

    Article  PubMed  Google Scholar 

  29. 29.

    Kakande I, Mkandawire N, Thompson MIW (2011) A review of surgical capacity and surgical education programmes in the COSECSA region. East Cent Afr J Surg 16:6–34

    Google Scholar 

  30. 30.

    Training/Curriculum: Pan African Academy of Christian Surgeons (2015).

  31. 31.

    Lum SK (2013) Evolving a common surgical curriculum for ASEAN nations with a public health approach. ANZ J Surg 83:118–121

    Article  PubMed  Google Scholar 

  32. 32.

    Association of Southeast Asian Nations: Association of Southeast Asian Nations (2014).

  33. 33.

    Kakande I (1991) Peptic ulcer surgery at a rural hospital in Kenya. East Afr Med J 68:15–20

    CAS  PubMed  Google Scholar 

  34. 34.

    Ajayi OO, Adebamowo CA (1999) Surgery in Nigeria. Arch Surg 134:206–211

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Bornman PC, Krige JE, Terblanche J et al (1996) Surgery in South Africa. Arch Surg 131:6–12 discussion 13

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Deckelbaum DL, Gosselin-Tardif A, Ntakiyiruta G et al (2014) An innovative paradigm for surgical education programs in resource-limited settings. Can J Surg 57:298–299

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Deckelbaum DL, Ntakiyiruta G, Liberman AS et al (2012) Augmenting surgical capacity in resource-limited settings. Lancet 380:713–714

    Article  PubMed  Google Scholar 

  38. 38.

    International Database: Global Partners in Anesthesia and Surgery (2012).

  39. 39.

    Operation Giving Back: American College of Surgeons (2015).

  40. 40.

    Talati JJ, Syed NA (2008) Surgical training programs in Pakistan. World J Surg 32:2156–2161. doi:10.1007/s00268-008-9639-0

    Article  PubMed  Google Scholar 

  41. 41.

    Limson AA, Danguilan LJ, Gutierrez RR et al (1999) Surgery in the Philippines. Arch Surg. 134:323–327

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Aphinives P (2013) Implementation of electronic logbook for trainees of general surgery in Thailand. J Med Assoc Thai 96:47–51

    PubMed  Google Scholar 

  43. 43.

    Goderich Lalan J (2010) Surgical education in Cuba. World J Surg 34:887–889. doi:10.1007/s00268-010-0515-3

    Article  PubMed  Google Scholar 

  44. 44.

    World Health Organization (2013) Transforming and scaling up health professional education and training: Policy brief on financing education of health professionals

  45. 45.

    Meara JG, Leather AJ, Hagander L et al (2015) Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569–624

    Article  PubMed  Google Scholar 

  46. 46.

    Dumurgier C, Baulieux J (2005) Renaissance of training in general surgery in Cambodia: a unique experience or reproducible model. Trop Med 65:80–86

    CAS  Google Scholar 

  47. 47.

    Dumurgier C, Baulieux J, Breda Y et al (2004) Renew of general surgery teaching in Kampuchea. Unique experiment or model? Ann Chir 129:616–619

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Zhao Y, Zhang X, Chang Q et al (2013) Psychometric characteristics of the 360 degrees feedback scales in professionalism and interpersonal and communication skills assessment of surgery residents in China. J Surg Educ 70:628–635

    Article  PubMed  Google Scholar 

  49. 49.

    Wan YC, Wan YI (2008) Delivering surgical training in the People’s Republic of China: are current mechanisms adequate? Int J Surg 6:443–445

    Article  PubMed  Google Scholar 

  50. 50.

    Rosin RD (2008) The uncertain path/journey into and through surgical training: an overview of different approaches and programmes in different countries. Int J Surg 6:281–286

    Article  Google Scholar 

  51. 51.

    Zhang YC, Hong HQ, Lin YT et al (1995) Surgery in China. Arch Surg. 130:1255–1259

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    Gunsentsoodol B, Nachin B, Dashzeveg T (2006) Surgery in Mongolia. Arch Surg. 141:1254–1257

    Article  PubMed  Google Scholar 

  53. 53.

    Kevau I, Watters DA (2006) Specialist surgical training in Papua New Guinea: the outcomes after 10 years. ANZ J Surg 76:937–941

    Article  PubMed  Google Scholar 

  54. 54.

    Watters DAK, Theile DE (2000) Progress of surgical training in Papua New Guinea to the end of the 20th century. Aust N Z J Surg 70:302–307

    CAS  Article  PubMed  Google Scholar 

  55. 55.

    Watters DA (1996) The future of surgery in Papua New Guinea and the South Pacific. Aust N Z J Surg 66:580–583

    CAS  Article  PubMed  Google Scholar 

  56. 56.

    Satar S, Cenkseven F, Karcioglu O et al (2005) An investigation of the anger levels of residents: medical compared with surgical disciplines. Postgrad Med J 81:653–656

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Alemdaroglu K (1999) Surgery in Turkey: past and present. Arch Surg 134:1017–1018

    CAS  Article  PubMed  Google Scholar 

  58. 58.

    Ferreira EA, Rasslan S (2010) Surgical education in Brazil. World J Surg 34:880–883. doi:10.1007/s00268-009-0264-3

    Article  PubMed  Google Scholar 

  59. 59.

    dos Santos EG (2009) General surgery residency in Brasil—very far from real practice. Revista do Colegio Brasileiro de Cirurgioes 36:271–276

    PubMed  Google Scholar 

  60. 60.

    Birolini D, Ferreira EA, Rasslan S et al (2002) Surgery in Brazil. Arch Surg 137:352–358

    Article  PubMed  Google Scholar 

  61. 61.

    Rodriguez Funes MV (2010) Surgical education in El Salvador. World J Surg 34:890–892. doi:10.1007/s00268-010-0500-x

    Article  PubMed  Google Scholar 

  62. 62.

    Leake PA, Qureshi A, Plummer J et al (2012) Minimally invasive surgery training in the Caribbean—a survey of general surgical residents and their trainers. West Indian Med J. 61(7):708–715

    CAS  PubMed  Google Scholar 

  63. 63.

    Fletcher P, McDonald A, McCartney T et al (2003) Surgery in Jamaica. Arch Surg 138:1150–1153

    Article  PubMed  Google Scholar 

  64. 64.

    Graue-Wiechers E (2011) Teaching surgery at the UNAM and some educational concepts. Cir Cir 79:60–69

    PubMed  Google Scholar 

  65. 65.

    Cervantes J (2010) Surgical education in Mexico. World J Surg 34:875–876. doi:10.1007/s00268-009-0124-1

    Article  PubMed  Google Scholar 

  66. 66.

    Orozco H, Mercado MA (2000) Surgery in Mexico. Arch Surg. 135:226–228

    CAS  Article  PubMed  Google Scholar 

  67. 67.

    Cervantes J, Cervantes A (1994) Health care delivery system. Effects on surgical education: the Mexican panorama. World J Surg 18:696–699. doi:10.1007/BF00298906 discussion 695

    CAS  Article  PubMed  Google Scholar 

  68. 68.

    el-Zawahry MD, Ramzy AF, el-Sahwi E et al (1997) Surgery in Egypt. Arch Surg 132:698–702

    CAS  Article  PubMed  Google Scholar 

  69. 69.

    Ghossain A, Freiha F, Geahchan N (2003) Surgery in Lebanon. Arch Surg. 138:215–219

    Article  PubMed  Google Scholar 

  70. 70.

    Tandon A (2010) Postgraduate surgical training in India. Indian J Med Ethics. 7:264–265

    PubMed  Google Scholar 

  71. 71.

    Mittal R, Perakath B (2010) Evidence-based surgery: knowledge, attitudes, and perceived barriers among surgical trainees. J Surg Educ 67:278–282

    Article  PubMed  Google Scholar 

  72. 72.

    Bansal PK, Saoji VA, Gruppen LD (2007) From a “generalist” medical graduate to a “specialty” resident: can an entry-level assessment facilitate the transition? assessing the preparedness level of new surgical trainees. Ann Acad Med Singapore 36:719–724

    PubMed  Google Scholar 

  73. 73.

    Kaushik SP (2002) Surgical training in India. Nat Med J India 15:282–283

    CAS  Google Scholar 

  74. 74.

    Mukerjee S, Gupta T (1997) Surgery in India. Arch Surg. 132:571–578

    CAS  Article  PubMed  Google Scholar 

  75. 75.

    Sameer ur R, Kumar R, Siddiqui N et al (2012) Stress, job satisfaction and work hours in medical and surgical residency programmes in private sector teaching hospitals of Karachi, Pakistan. JPMA. J Pak Med Assoc 62:1109–1112

    Google Scholar 

  76. 76.

    Ali IS, Khan M, Khan A et al (2012) Trainees’ feedback on the prevailing teaching methods in postgraduate medical institute, Lady Reading Hospital, Peshawar, Pakistan. J Coll Phys Surg Pak 22:317–319

    Google Scholar 

  77. 77.

    Khan MA, Hussain S, Siddiqui F (2007) Training general surgery residents in paediatric surgery. J Pak Med Assoc 57:257–258

    PubMed  Google Scholar 

  78. 78.

    Mutabdzic D, Bedada AG, Bakanisi B et al (2013) Designing a contextually appropriate surgical training program in low-resource settings: the Botswana experience. World J Surg 37:1486–1491. doi:10.1007/s00268-012-1731-9

    Article  PubMed  Google Scholar 

  79. 79.

    Brobby GW, Ofosu-Barko FO (2002) Developing appropriate community-based postgraduate training in a developing country. Educ Health 15:3–9

    CAS  Article  Google Scholar 

  80. 80.

    Mains EA, Blackmur JP, Dewhurst D et al (2011) Study on the feasibility of provision of distance learning programmes in surgery to Malawi. Surgeon 9:322–325

    Article  PubMed  Google Scholar 

  81. 81.

    Oginni FO, Fagade OO, Temisaren TO et al (2007) Attitude of Nigerian surgical residents towards trauma care. Niger Postgrad Med J 14:105–108

    CAS  PubMed  Google Scholar 

  82. 82.

    Adebamowo CA, Ezeome ER, Ajuwon AJ et al (1998) Job stress associated with surgical training in Nigeria. Afr J Med Med Sci 27:233–237

    CAS  PubMed  Google Scholar 

  83. 83.

    Nmadu PT (1996) Trends in staffing an academic department of surgery in a tropical hospital: past, present, and future? Br Med J 312:1345–1347

    CAS  Article  Google Scholar 

  84. 84.

    Degiannis E, Oettle GJ, Smith MD et al (2009) Surgical education in South Africa. World J Surg 33:170–173. doi:10.1007/s00268-008-9815-2

    Article  PubMed  Google Scholar 

  85. 85.

    Goosen J, Veller M (2008) Trauma and emergency surgery: South African model. World J Surg 32:1622–1625. doi:10.1007/s00268-008-9573-1

    CAS  Article  PubMed  Google Scholar 

  86. 86.

    Dent DM (1998) Surgical training in 21st-century Africa—a South African perspective. Presented at the General Assembly of the Pan African Association of Surgeons, January 1998, Abuja, Nigeria. South African Journal of Surgery. Suid-Afrikaanse tydskrif vir chirurgie. 36:44, 46

  87. 87.

    Thomson SR, Baker LW (1994) Health care provision and surgical education in South Africa. World J Surg. 18:701–705. doi:10.1007/BF00298908. discussion 700

  88. 88.

    College of Surgeons Training: Academy of Medicine of Malaysia (2015)

  89. 89.

    PCS Fellowship: Philippine College of Surgeons (2013)

  90. 90.

    Postgraduate: The Medical Council of Thailand (2015)

  91. 91.

    Graduate Programmes: The University of the West Indies at Mona, Jamaica (2015).

  92. 92.

    Postgraduate Medical Education Regulations, 2000 (Amended up to May 2013): Medical Council of India (2010).

  93. 93.

    National Academy of Medical Sciences (India): National Academy of Medical Sciences (India) (2015).

  94. 94.

    Training Program: College of Physicians and Surgeons Pakistan (2015).

  95. 95.

    Training and Exams: College of Surgeons of East, Central and Southern Africa (2015).

  96. 96.

    Ghana College of Physicians and Surgeons Postgraduate Training and Residency Programmes Rules and Regulations: Ghana College of Physicians and Surgeons (2014).

  97. 97.

    Ojo EO, Chirdan OO, Ajape AA et al (2014) Post-graduate surgical training in Nigeria: The trainees’ perspective. Niger Med J 55:342–347

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  98. 98.

    National Postgraduate Medical College of Nigeria: National Postgraduate Medical College of Nigeria (2015)

  99. 99.

    Fellowship of the College of Surgeons of South Africa: FCS(SA): The Colleges of Medicine of South Africa (2015).

  100. 100.

    Dreyer J, Hannay J, Lane R (2014) Teaching the management of surgical emergencies through a short course to surgical residents in East/Central Africa delivers excellent educational outcomes. World J Surg 38:830–838. doi:10.1007/s00268-013-2320-2

    Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Jennifer Rickard.

Ethics declarations

Conflicts of interest

The author has no disclosures or conflicts of interest to report. The author did not receive financial or grant support for this research.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Rickard, J. Systematic Review of Postgraduate Surgical Education in Low- and Middle-Income Countries. World J Surg 40, 1324–1335 (2016).

Download citation


  • Training Program
  • Postgraduate Training
  • Postgraduate Program
  • Postgraduate Training Program
  • Private Sponsorship