Contextualizing Surgical Training Disparities​

The maldistribution of surgical training opportunities limits equitable access to safe surgical care across rural sub-Saharan Africa (1). This imbalance is a result of historically centralized postgraduate surgical education in urban areas, with few surgeons returning to rural or peripheral hospitals after training (1). Addressing this challenge requires the implementation of a decentralized accreditation and training framework. The College of Surgeons of East, Central and Southern Africa (COSECSA) established this decentralized surgical training model. By offering postgraduate training within accredited hospitals rather than confining training to urban academic centers, COSECSA’s model shows that training surgeons in accredited peripheral regional, district, and faith-based hospitals may improve surgeon retention in rural areas and thereby contribute to improved healthcare access in underserved communities (2).
This model has expanded postgraduate surgical training in Kenya, and this decentralized hospital-based model has since been adopted in more than 15 countries. Today, COSECSA supports surgical training across 145 accredited hospitals in 20 countries, involving over 1300 trainees, more than 900 trainers, and over 1048 graduates, and has one of the broadest geographic reaches of any surgical training organization in Africa (3, 4).
This editorial examines Kenya’s journey of implementing COSECSA’s decentralized accreditation model and offers this experience as an example that may provide insight into other resource-limited countries considering similar approaches to surgical training.

 

Foundations of COSECSA Accreditation in Kenya
Kenya’s engagement with COSECSA accreditation began in 2003, enabling the college to administer its inaugural Membership of the College of Surgeons (MCS) examination. By 2004, 10 Kenyan hospitals had obtained accreditation (4). The MCS pathway qualified candidates with a 2-year postgraduate credential to pursue advanced surgical training; however, a formal regulatory framework was required to legally license the graduates.
In 2007, the Medical Practitioners and Dentists Board (MPDB) of Kenya (now known as the Kenya Medical Practitioners and Dentists Council) formally recognized surgical fellowship as a distinct specialty that provided the regulatory foundation necessary to legitimize decentralized training pathways, ensuring that COSECSA graduates could be registered to practice as qualified surgeons. This policy advancement strengthened regulatory oversight of non-university-based COSECSA training sites. This included site visits to COSECSA-accredited hospitals in various parts of the country leading to accreditation and re-accreditation of training sites. This process helped establish national training standards and promote quality of care across participating hospitals.

Financial Hurdles
The requirement for an accreditation fee per hospital, mandated by the MPDB, limited the expansion of decentralized surgical training in public and rural facilities in Kenya.

To alleviate financial burdens, philanthropic support helped procure centralized equipment and stakeholder advocacy led to a temporary policy change. The Pan-African Academy of Christian Surgeons (PAACS) {A deletion was made here} provided USD 5000 to cover board-mandated accreditation fees for PAACS mission hospitals. This resulted in the MPDB designating Tenwek Hospital, Kijabe Hospital, PCEA Kikuyu Hospital, Kenyatta National Hospital, and Moi Teaching and Referral Hospital as Kenya’s first five COSECSA-accredited training sites. Furthermore, in 2018, with additional donations from the Kleitjen Foundation (Boston, USA), eight peripheral hospitals were accredited.
Moreover, the Managed Equipment Services arrangement implemented in 2015 equipped 98 hospitals across Kenya’s 47 counties with essential surgical equipment (5).
To bring about broader structural change, workforce action was needed at a national level. At the 2018 World Health Assembly in Geneva, an appeal for the accreditation of additional training hospitals eligible under COSECSA’s accreditation standards was made (4, 6). This meeting resulted in the formation of the Medical Specialist Training Task Force, co-chaired by Prof. Jani. Advocacy through this initiative led to the temporary removal of the MPDB-mandated KES 250,000 accreditation fee, leading to the accreditation of 11 additional hospitals in Kenya, increasing the number of approved training sites to 24 and expanding certification capacity to approximately 60 surgeons annually (7, 8). The temporary elimination of the accreditation fee was an important policy change that enabled rural and county-level hospitals to better realize their training potential.

Kenya’s Impact and Lessons from Surgical Training Accreditation
Kenya’s case study offers insights that extend beyond its borders. Its experience accrediting COSECSA training sites demonstrates the importance of strategic leadership, advocacy, and policy reform in expanding surgical education.
Kenya’s approach to implementing the decentralized surgical training accreditation model resulted in sustained expansion. From 2006 to 2025, the average annual number of Kenya’s COSECSA graduates increased from approximately 6 in the first decade to about 38 in the last 5 years (9). Kenya played a foundational role in COSECSA’s early surgical training expansion by contributing about 30–60% of annual graduates during the formative years of the college (Figure 1). Although Kenya’s proportional contribution later declined as training capacity expanded across additional member countries, its graduate output remained stable at 25–32% relative to COSECSA’s total graduates (Figure 1).

 

Figure 1.

Comparison of Kenya’s annual College of Surgeons of East, Central and Southern Africa (COSECSA) graduates with the total graduates across the broader COSECSA network from 2006 to 2025 (10).

Equitable access to surgical care in rural sub-Saharan Africa now depends on joint efforts and investments made by national health authorities, health science colleges, and hospital leadership.
National health authorities providing sustained grant funding for collegiate training programs such as COSECSA can help improve infrastructure development, training quality, educational courses, and trainee stipends/salaries. Regional and independent partnerships can help supplement funding where national resources are limited.
Sub-Saharan African health science colleges can advance surgical training by integrating digital innovations. Training quality is being further standardized through electronic registration, logbooks, and assessment tools. Furthermore, remote supervision platforms, virtual didactic sessions, and simulation training sessions (“Sim Labs”) may help address geographic discrepancies and standardize surgical education across rural and urban centers.
By establishing COSECSA Centers of Excellence, national hospital leadership can create a pathway for national champions to facilitate communication between hospital leadership and government/regulatory institutions. Countries in the COSECSA network can support each other’s pursuit of an equitable surgical future by supporting surgical training systems in peer nations, providing technical surgical assistance and mentorship, and engaging in policy dialogue.
Working together to implement a decentralized accreditation model of surgical training will pave the way for equitable access to healthcare across rural sub-Saharan Africa.

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Author contributions

PJ lead in writing of the original draft. All authors equally contributed to reviewing & editing of the original draft.

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References

1. O’Flynn E, Andrew J, Hutch A, et al. The Specialist Surgeon Workforce in East, Central and Southern Africa: a situation analysis. World J Surg. 2016;40(10):2315-20.

2. Bekele A, Alayande BT, Iradukunda J, et al. A cross-sectional survey on surgeon retention in the COSECSA region after specialist training: have things changed? World J Surg. 2024;48(4):829-42.

3. College of Surgeons of East, Central and Southern Africa. Available fromhttps://www.cosecsa.org.

4. COSECSA Education, Scientific and Research Committee. COSECSA training manual. Arusha: College of Surgeons of East, Central and Southern Africa. 2018. Available fromhttps://www.cosecsa.org/wp-content/uploads/2023/09/COSECSA_Training_Manual.pdf.

5. Tierney S, et al. Innovations in surgical education in LMICS. World J Surg. 2019;43(2):345-52.

6. Njagi E, Iloka K, Wawira S, Thiga L, Muraguri N. Learning from the Kenyan experiment: key takeaways for implementing managed equipment services in developing countries. Front Health Serv. 2025;5: 1361261.

7. College of Surgeons of East, Central and Southern Africa (COSECSA). Kenya Country Office: internal country office reports 2010–2020. Arusha: COSECSA. 2020.

8. G4 Alliance. The G4 Alliance. 2023. Available fromhttps://www.theg4alliance.org.

9. College of Surgeons of East, Central and Southern Africa (COSECSA). Internal data on MCS examination cycles. Arusha: COSECSA Headquarters. 2024.