Top 5 Surgical Education Innovations for Low‐Resource Settings Over the Last 50 years

1. Introduction

The global surgical education landscape has transformed significantly over the last 50 years. The shift from traditional Halstedian apprenticeship models to structured, competency‐based paradigms has proven especially beneficial in resource‐constrained settings, where geographic isolation, limited specialist availability, and restricted case exposure limit training opportunities. This is enhanced by digital learning platforms, remote mentorship networks, and artificial intelligence‐enabled tools [1, 2, 3, 4]. While five key global innovations in surgical education have been described elsewhere in this series, this article takes a complementary approach, using a framework comprising six domains (Accessibility, Availability, Affordability, Adaptability, Adoptability, and Sustainability) to examine and present five surgical education innovations that have particular relevance to resource‐constrained settings.

1.1. Defining Our 6‐Domain Framework

Building on the widely used Penchansky and Thomas 5A framework, we developed a framework comprising four of the five original access components: Availability, Accessibility, Affordability, and Adaptability [5], with two other modifications: Adoptability and Sustainability. First: Acceptability, the fifth component which addresses attitudinal and cultural receptiveness to an intervention, was replaced with Adoptability. This is because Adoptability captures the practical and structural conditions required for an intervention to take root and be retained within a given system. In resource‐constrained settings, this distinction is particularly important, as the key question is rarely whether an innovation is welcomed in principle, but whether it can realistically be implemented and sustained given available infrastructure, workforce capacity, and institutional support—limitations that are often the primary determinants of feasibility rather than secondary implementation concerns. Second: Sustainability was added to explicitly foreground the infrastructural, financial, curricular, and workforce conditions that determine whether surgical training innovations can be maintained over time. By operationalizing these six domains, our framework enables narrative comparison across interventions and clarifies the conditions necessary for equitable and scalable implementation. Using this framework (Figure 1), we now examine five key technological innovations in surgical education, evaluating each through the lens of our established framework to assess their feasibility and relevance in resource‐constrained settings.

FIGURE 1.

Conceptual framework for assessing surgical education innovations in low‐ and middle‐income settings.

1.2. The Key Innovations in Surgical Education in Resource‐Constrained Settings

1.2.1. Frugal Simulation Tools and Trainers

Simulation‐based surgical training has transformed how technical skills are acquired globally, but its application in resource‐constrained settings has followed a distinctly different trajectory to that seen in high‐income countries. Where well‐resourced programmes have increasingly turned to high‐fidelity virtual reality and robotic simulators, LMIC training environments have demonstrated that approximately 80% of simulation‐based learning can be achieved through low‐cost, locally sourced materials and task trainers [6]. This pragmatic evolution (often termed frugal simulation) is not a compromise; it is an innovation, albeit a frugal innovation, in its own right.

Frugal simulators, including box trainers, locally made anatomical models, and repurposed materials for procedural skills practice, have demonstrated effective skills transfer in laparoscopic, obstetric, and general surgical training in LMIC settings [7, 8]. Their development has frequently been led by LMIC faculty and trainees themselves, producing solutions that reflect local operative realities, available instruments, and prevalent disease burdens in ways that commercially developed simulators rarely do. The GlobalSurgBox, for example, a low‐cost, modular and portable box simulator, was found to be especially useful in equipping medical students and trainees from across various contexts [9].

Overall, across the six domains, frugal simulation is among the strongest performers on this list. Affordability and Adoptability are its defining strengths: low purchase costs and minimal infrastructure requirements mean that programmes can be initiated and sustained without heavy investments. Accessibility is improved by removing the need for specialist facilities, and Adaptability is inherently high given that models can be designed around local clinical priorities. Availability depends on faculty capacity to deliver structured simulation curricula, which remains variable. Sustainability is most durable where frugal simulation is formally embedded within accredited training programmes rather than delivered as standalone workshops, and where local faculty are equipped to train the trainers.

1.2.2. Scalable Digital E‐Learning Ecosystems

For surgical trainees in resource‐constrained settings, the most persistent educational barrier is often not motivation or aptitude but simple lack of access to current, high‐quality learning material. Structured digital e‐learning platforms have addressed this more effectively than any print‐based resources. Platforms such as WebSurg (IRCAD) provide curated operative videos, competency‐based modules, and standardised learning materials designed for integration into formal training pathways rather than informal self‐directed browsing [10, 11]. Unlike informal online content, many undergo expert review and align with curriculum objectives, allowing incorporation into competency‐based programmes. The ability to learn asynchronously and at a self‐suited pace offers particular value in surgical residencies of variable duration across different countries [12]. When built with low‐bandwidth functionality, comprising compressed video, downloadable modules, and transcript‐based content, they can reach trainees where connectivity is unreliable [13].

Thus, across the six domains, digital e‐learning platforms perform well for Availability where digital repositories exist, and lower connectivity is adjusted for. When considering Adoptability, what distinguishes more successful digital ecosystems from simple content repositories is governance. Regional bodies such as the College of Surgeons of East, Central and Southern Africa (COSECSA) have integrated shared digital content into accredited training pathways, giving e‐learning genuine curricular standing rather than optional supplement status [14]. Where collaborations prioritize local faculty development and curriculum co‐design over content transfer alone, longer‐term Sustainability becomes achievable rather than aspirational.

However, limitations remain. Regarding Affordability, subscription‐based platforms remain unaffordable for many institutions without pooled or nationally negotiated access. While digital content is accessible, Accessibility as a whole is limited by a lack of protected learning time where service delivery pressures dominate. Furthermore, externally developed curricula do not always authentically reflect local disease burdens, available instrumentation, or operative realities. Consequently, without deliberate contextualisation e‐digital content risks being educationally accessible but situationally irrelevant [15, 16, 17].

1.2.3. Tele‐Mentoring & Tele‐Proctoring Networks

In many LMIC settings, the limiting factor in surgical training is not the willingness of trainees to learn but the absence of anyone nearby to guide them. Subspecialty expertise is often concentrated in fewer urban centers, structured mentorship pathways are inconsistent, and overseas fellowships, while valuable, are expensive, time‐bound, and inaccessible to the majority. Tele‐mentoring and tele‐proctoring networks offer a practical alternative by bringing expert guidance directly into local surgical training without requiring either party to travel; this is directly demonstrated through organisations such as OhanaOne through their Vuzix Smart Glasses and Helping Lighting software.

The evidence base is most developed in minimally invasive surgery, where real‐time tele‐proctoring through secure video platforms and telestration tools has demonstrated safety and learning outcomes comparable to in‐person supervision, at significantly lower cost and with less disruption to local service delivery [18, 19]. Beyond intraoperative supervision, structured digital networks enable ongoing case‐based discussion, longitudinal mentorship, and multidisciplinary engagement. This model is particularly relevant where faculty density is low and subspecialty backup is absent [20, 21].

Across the six domains, tele‐mentoring expands Accessibility by connecting district‐level surgeons with expertise at higher centers, improves Availability through sustained rather than visit‐dependent mentorship, and reduces the Affordability burden of extended travel‐based training. Flexible platforms can be tailored to local clinical needs, supporting Adaptability. The central Sustainability challenge is maintaining engagement over time. Structured programmes with defined governance and protected faculty time outperform informal arrangements, which tend to depend on individual relationships and are vulnerable to attrition [22].

1.2.4. Artificial Intelligence‐Enabled Adaptive Learning and Decision‐Support Tools

Artificial intelligence (AI) is entering surgical education rapidly, and the range of applications is broad: adaptive learning platforms that personalize content to individual trainee needs, large language models that generate practice questions and summarize literature, automated video analysis for intraoperative performance evaluation, and OSATS‐based tools for objective technical skills scoring [23, 24, 25, 26]. For LMIC settings where faculty capacity for individualized feedback is constrained, the theoretical appeal is considerable; AI tools could potentially augment limited supervision and extend the reach of structured assessment [27].

In practice, the gap between theoretical potential and demonstrated LMIC impact remains wide. Most AI platforms have been developed and validated using data from high‐income health systems, raising legitimate concerns about contextual misalignment. Large language models can generate plausible but incorrect clinical responses [28], and automated performance scoring tools require rigorous validation across diverse training environments before they can be trusted for high‐stakes assessment. Concerns around data privacy, medico‐legal responsibility, and the risk of deskilling through over‐reliance further complicate implementation [29].

Across the six domains, AI tools show promise on Accessibility and Availability where cloud‐based systems require minimal hardware, and on Adaptability through personalized learning pathways. Though Affordability remains a barrier given subscription‐based pricing models, free‐to‐use models offer basic functionality. More so, Adoptability is significantly constrained by connectivity requirements and the absence of LMIC‐validated tools. Sustainability depends on regulatory frameworks, data governance, and institutional trust that remain underdeveloped in most LMIC contexts. AI‐enabled tools may meaningfully augment surgical education in resource‐constrained settings, but implementation should follow validation rather than precede it.

1.2.5. Surgical Training for Non‐Surgeons

The surgical workforce deficit remains one of the most fundamental barriers to equitable surgical care. The 2015 Lancet Commission on Global Surgery estimated that 143 million additional procedures were needed annually in LMICs to address preventable morbidity, a figure more recent estimates place closer to 160 million [30, 31]. Many LMICs fall far below the Commission's recommended benchmark of 20 surgical, anesthesia, and obstetric providers per 100,000 population, and physician‐only training models cannot close this gap within any realistic timeframe.

Task‐sharing (the structured training of non‐physician clinicians to perform defined surgical procedures) represents perhaps the most significant and distinctively LMIC‐generated innovation in surgical education of the past 50 years. Unlike most advances in surgical education, the surgical training of non‐surgeons was an LMIC‐led solution: born out of necessity due to a significant provider‐patient gap within resource‐limited contexts. Countries including Mozambique, Malawi, Ethiopia, and Nigeria have formalized programmes in which clinical officers, assistant physicians, and general practitioners are trained to perform procedures such as caesarean sections, hernia repairs, appendicectomies, and wound debridement, with outcomes comparable to physician‐delivered care in the same settings [32, 33, 34].

Across our six domains, task‐sharing performs strongly. It directly addresses Availability and Accessibility by expanding the workforce in underserved areas, and Affordability through lower training and deployment costs. Adoptability is well demonstrated by the breadth of country‐level implementation. The primary challenges lie in Adaptability and Sustainability: training curricula remain heterogeneous across contexts, quality assurance mechanisms are inconsistent, and long‐term program continuity depends on political will and protected funding [35]. Sustainability is further complicated by workforce retention, since trained non‐physician providers are vulnerable to attrition through migration or role drift without structured career pathways and ongoing institutional support. Standardizing competency frameworks across LMIC settings, while preserving flexibility for local disease burdens and operative realities, is the central implementation priority.

1.3. Recommendations

We present a six‐domain framework to guide surgical programs in evaluating and implementing educational innovations (Figure 2). This framework offers a shared conceptual language to support comparative research and guide context‐specific deployment of innovations.

FIGURE 2.

Heat Map Reflecting a Qualitative Assessment of Surgical Education Innovations in Low‐ and Middle‐Income Settings using a 6‐Domain Framework.

Importantly, not all innovations will be appropriate for every setting, and the six domains provide a pragmatic lens for making those determinations (Table 1). Efforts to enhance Accessibility and Availability (such as shared digital infrastructure and subsidized connectivity) should intentionally prioritize reach beyond well‐resourced academic centers. Addressing Affordability will require strategies including pooled procurement and tiered pricing models to prevent the concentration of advanced educational tools in settings where marginal benefit is lowest.

TABLE 1.

Narrative summary of five surgical education innovations assessed across a six‐domain framework for low‐ and middle‐income country contexts.

Domain	Frugal simulation Tools & trainers	Digital E‐learning	Tele‐mentoring & Tele‐proctoring	AI‐enabled learning & tools	Surgical training for non‐surgeons
Accessibility	Strong	Moderate	Strong	Moderate	Strong
	No specialist facilities required	Requires protected learning time	Connects district‐level surgeons with needed expertise	Possible where cloud‐based systems require minimal hardware	Expanded surgical reach in underserved areas
Availability	Moderate	Moderate	Moderate	Moderate	Strong
	Dependent on local faculty capacity	Requires existing digital repositories and adequate connectivity	Requires robust digital networks and adequate connectivity	Undermined by connectivity constraints	Expanded workforce in underserved areas
Affordability	Strong	Moderate	Strong	Limited	Strong
	Low purchase costs	Open‐access repositories partially offset the subscription barrier	No travel‐based training required	Subscription‐based pricing is a barrier; free‐to‐use models offer limited functionality	Lowered training and deployment costs
Adaptability	Strong	Limited	Strong	Moderate	Moderate
	Locally contextual models can be designed	Externally developed curricula do not always reflect local the context	Platforms can be tailored to local needs	Empowers personalized learning pathways	Heterogeneous training curricula across contexts; inconsistent quality assurance mechanisms
Adoptability a	Strong	Moderate	Moderate	Limited	Moderate
	Minimal infrastructure requirements	Dependent on digital governance and stakeholder buy‐in	Dependent on stakeholder buy‐in and existing infrastructure	Due to connectivity constraints and a lack of LMIC‐validated tools	Requires country‐level policy adoption and stakeholder buy‐in
Sustainability b	Moderate	Moderate	Moderate	Limited	Moderate
	Requires formal integration into accredited training programmes	Possible when local collaborations and co‐development prioritized	Requires defined governance and protected faculty‐time in the long‐term	Dependent on regulatory frameworks, data governance, and institutional trust	Dependent on political will and requires protected funding

Note: Ratings are author‐assigned qualitative assessments based on the evidence synthesis presented and not on quantitative scoring.

^a Adoptability: adapted from acceptability (Penchansky & Thomas, 1981) to capture the structural and infrastructural conditions required for implementation.

^b Sustainability: newly added domain to highlight conditions required for long‐term maintenance of the above innovations.

Adaptability necessitates the co‐development of platforms and curricula with local faculty, rather than the unmodified transfer of models designed for fundamentally different contexts. Most critically, Adoptability and Sustainability must be treated as prerequisites for scale‐up rather than downstream considerations. Innovations that cannot be embedded within existing training structures or sustained without ongoing external support are unlikely to meaningfully reduce educational inequities, regardless of their initial promise.

2. Conclusion

The innovations examined here share a common lesson: technological potential and educational impact are not the same thing. In resource‐constrained settings, what determines whether an innovation transforms surgical training is rarely the sophistication of the tool but the conditions surrounding its implementation. A surgical workforce adequate to meet LMIC needs cannot be built by simply importing solutions designed elsewhere; it has to be built by investing in the infrastructure, faculty, and governance frameworks that allow innovation to take root and last.

Author Contributions

Udit Choubey: conceptualization, writing – original draft, writing – review and editing. Cassandra Mbanje: conceptualization, writing – review and editing, project administration, writing – original draft. Rajeeka Singh Tak: writing – original draft. Jessica Davies: writing – review and editing. Mariela Rivera: supervision, writing – review and editing, conceptualization.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.