Strengthening Surgical Systems Through National Plans: Lessons from NSOAP Implementation in LMICs

Introduction: Roughly 5 billion people lack access to affordable, safe, and timely surgical care (Lancet Commission on Global Surgery, 2015). The development of National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) has emerged as a powerful driver for integrating surgery into broader efforts to improve health systems in low- and middle-income countries (LMICs). Methodology: A systematic review of the policy context in which NSOAPs were developed and implemented was undertaken in Ethiopia, Tanzania, Rwanda, Nigeria, Zambia, and Ecuador to determine common strategies, achievements, and challenges by examining planning reports, published evaluations, and secondary interviews. Results: All reviewed NSOAPs prioritized scaling the surgical workforce, expanding district-level surgical capacity, and establishing surgical data systems. Ethiopia’s NSOAP led to a 14-fold increase in surgical provider density over four years, while Rwanda doubled its number of surgeons and anesthesiologists within five years. Challenges included limited domestic financing and dependence on external partners. Political engagement and cross-sector collaboration (e.g., ministries of health, education, and finance) were important for successful implementation. Conclusions: NSOAPs provide a strong, transdisciplinary strategy for strengthening surgical systems. Lessons learned from the early implementers include the key importance of political commitment, long-term financial support, and intersectoral collaboration. Development of NSOAPs, as well as continuous monitoring and revision, is a useful benchmark and tool in advancing equitable access to surgical care globally.