Assessing Compliance with the WHO Surgical Safety Checklist in Rwanda and Malawi: A Mixed-Methods Study of Systemic and Behavioural Barriers

Introduction: The WHO Surgical Safety Checklist (WHO SSC) is a low-cost, high-impact tool shown to improve surgical outcomes and enhance safety culture, particularly in low- and middle-income countries (LMICs). Despite its effectiveness, adherence remains inconsistent across resource-constrained settings. This study evaluated WHO SSC availability and compliance in Rwandan and Malawian hospitals, identifying systemic and behavioural factors influencing implementation. Methods: A prospective observational study and cross-sectional staff survey were conducted in 28 referral and district hospitals in Rwanda and Malawi. Surgical cases were selected using stratified random sampling, and checklist adherence was assessed via structured observation across the three checklist phases. Theatre staff completed questionnaires on checklist familiarity, training, and team dynamics. Statistical analysis included descriptive methods and generalised linear models to identify predictors of checklist availability and use. Results: Of 602 surgical procedures observed, checklist availability was significantly higher in referral hospitals (62%) than in district hospitals (30%), and in elective (56%) versus emergency surgeries (38%). Availability was lower in Rwanda (31%) compared to Malawi (69%) (p < 0.01), yet Rwandan hospitals demonstrated superior adherence across all phases: Sign-In (estimate = 29.4, p < 0.01), Time-Out (15.8, p < 0.01), and Sign-Out (15.2, p < 0.01). Team presence during Time-Out increased checklist use eleven-fold (OR: 11.8, 95% CI: 6.56–21.33). Familiarity with the checklist and 5–10 years of experience also improved compliance. Discussion: Despite broad awareness, checklist use in LMICs remains inconsistent due to logistical barriers and workforce dynamics. Targeted training, increased checklist availability, and digital tools may strengthen implementation and enhance surgical safety in under-resourced settings.