A Contract-based Surgical Group Model: A Sustainable Approach To Expanding Surgical Access In Malawi’s Mission Hospitals

Access to surgical care in Malawi remains severely limited, particularly in mission hospitals, which serve a large proportion of the population, especially in rural areas. These hospitals struggle to retain specialist surgeons due to financial constraints and the inability to offer competitive salaries. With the growing realization that both mission and public hospitals cannot afford the number of specialists required to ensure proper surgical coverage, new approaches are needed. In many high-income countries, such as the United States, group surgical practices contract with hospitals to provide comprehensive, on-demand surgical services. Inspired by this model, we have established the Healing Hands Surgical Group (HHSG), a contract-based surgical practice that provides on-demand surgical coverage for three mission hospitals in Northern Malawi—Ekwendeni, Embangweni, and David Gordon Memorial Hospital—on a per-patient basis. Methods & Implementation Contract-Based Model: Instead of full-time employment, the hospitals contract HHSG on a per-case basis, allowing financial flexibility while ensuring continuous surgical care. Rotational Surgical Coverage: A team of surgeons operates on a scheduled rotation, ensuring regular, predictable surgical services across the network hospitals. Preliminary Outcomes Since February 2025, when HHSG was launched, the model has been enthusiastically received by the hospitals. Initial anecdotal results indicate: Significant increase in surgical procedures performed. Improved patient outcomes due to consistent access to skilled surgical specialists. Cost savings for hospitals, allowing for reinvestment in infrastructure and essential medical supplies. Increase revenue for the hospitals. The contract-based surgical group model presents an innovative, scalable, and financially sustainable approach to addressing the shortage of specialist surgeons in low-income settings. By providing flexibility, cost-effectiveness, and improved access to surgical care, this model has the potential to be replicated in other mission hospitals and resource-limited regions, ultimately contributing to better health outcomes and reduced disparities in surgical access.