Barnabas Tobi Alayande

Effective management of biomedical equipment prevents breakdowns, extends equipment lifespan, ensures perioperative safety and cost-efficiency. There are major challenges in managing biomedical equipment, particularly in low- and middle-income countries. This study aimed to assess the availability, functionality, and adherence to maintenance practices of biomedical equipment in operating rooms (ORs) and post-anaesthesia care units (PACUs) across Rwanda. A cross-sectional observational study was conducted at one Level 2 district hospital in each of Rwanda’s five provinces (n=5 sites). Data were collected using three main tools: 1) a medical equipment checklist, 2) a checklist for hospital biomedical management, and 3) direct inspections of selected biomedical equipment. All tools underwent pretesting and face validation with support from biomedical experts prior to data collection in May 2024. Key measures, including the availability and functionality of biomedical equipment, and adherence to maintenance and management practices, were summarised using descriptive statistics. The five hospitals had a total of 16 ORs, 4 PACUs, and 226 pieces of equipment. The overall availability of biomedical equipment was 45%, and the functionality of the available equipment was 96%. The mean adherence rate to national management practices was 66%. The Rwandan government, non-governmental organisations, and hospitals were identified as direct funders of the equipment, accounting for 42%, 12%, and 4%, respectively. However, 42% of the equipment surveyed could not be linked to any of the above sources of acquisition. Among non-functional equipment, 75% was due to a lack of spare parts, while 25% was due to a lack of skills to maintain the equipment. In summary, we found low availability of perioperative biomedical equipment across Rwanda, although the available equipment was highly functional. Adherence to national management practice guidelines was relatively low, threatening the sustainability of functional equipment. We recommend that the government and hospital administrators implement robust, regular auditing systems to ensure proper management of biomedical equipment.

Background: Access to safe, timely, and affordable surgical care remains a challenge in low‐ and middle‐income countries (LMICs), where deficits in infrastructure and workforce are most acute at the district hospital level. From 2018 to 2024, Rwanda implemented its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP) and prioritized decentralized surgical care. We aimed to conduct a post‐implementation national assessment of surgical infrastructure, workforce, and service delivery at Rwanda's district and level 2 teaching (L2TH) hospitals. Methods: We conducted a nationwide cross‐sectional survey of 43 hospitals, comprising all 34 district hospitals, and 9 L2TH in Rwanda from May‐June 2025, using the WHO Situational Analysis Tool for Emergency and Essential Surgical Care (SAT‐EESC). Five domain‐specific informants per facility provided infrastructure, workforce, and service delivery data, complemented by facility walk‐throughs and a review of operating room registers. In addition to descriptive data analysis, we compared rural and urban hospitals and mapped workforce distribution. Results: All facilities had at least one functional operating room. Most facilities reported continuous electricity and running water, and oxygen cylinders were available at all times in 90.7% of facilities. Blood banks and oxygen concentrators were the least consistently available, reported as available at all times in 32.6% and 58.1% of facilities, respectively. The median facility‐level surgeon, anesthesiologist, and obstetrician density was 0.71 per 100,000 population, and 14 hospitals had no specialist SAO cadre. Non‐specialist cadres were widely available, with a median non‐specialist surgical workforce density of 6.76 per 100,000 population. No statistically significant urban–rural workforce differences were observed, although rural facilities were significantly farther from next‐level referral facilities. Conclusion: Rwanda's district and level 2 teaching hospitals demonstrate high infrastructure readiness. However, gaps persist in the distribution of the specialist workforce, diagnostics, and advanced surgical care capacity. The findings also highlight the importance of non‐specialist cadres in sustaining district‐level surgical service delivery.

Vaccination remains one of the most cost-effective interventions for reducing childhood morbidity and mortality from vaccine-preventable diseases. Despite global progress, vaccination coverage has recently declined, particularly in low- and middle-income countries (LMIC). In Rwanda, national childhood vaccination coverage is at 95%, yet gaps persist in reaching last-mile and hard-to-reach populations. Community Health Workers (CHWs) play a critical role in promoting and delivering vaccination services at the community level. However, evidence on their specific contributions, particularly in rural settings such as Burera District in Northern Rwanda, remains limited. This study aimed to (1) describe CHW-reported and perceived factors influencing their involvement in promoting childhood vaccination, (2) describe self-reported CHW roles in vaccination activities among children under five, and (3) explore caregivers' perspectives on CHWs' involvement in childhood vaccination. A mixed-methods study design was employed, combining a quantitative survey of 345 CHWs with individual interviews from 5 children's caregivers who benefited from community-based vaccination interventions conducted across 5 health centers in Burera District. Quantitative data were collected using structured questionnaires in REDCap and analyzed descriptively using STATA version 18. Qualitative data were analyzed using thematic analysis. Most CHWs were female (67.5%), married (98.8%), had primary-level education (86.1%), and were engaged in farming (98.6%). Nearly all CHWs had received vaccination-related training (94.5%) and considered children under-5 years of age vaccination very important (98.3%). Over half reported facilitating vaccination activities twice per month, and 93.9% were involved in community mobilization and campaign planning. Key activities included referring children to health facilities (58.0%) and conducting home-based vaccination outreach (42.0%). Caregivers highlighted CHWs' roles in health education, appointment reminders, and home-based services, emphasizing strong trust and their function as links between communities and the formal health system. Identified challenges included logistical constraints, the need for more consistent training and communication support. More than half of CHWs recommended strengthening structured community awareness, intervention and provision of monetary incentives for improving vaccination service delivery and community engagement. The perceived roles and self-reported practices showed that CHWs play a central role in sustaining high childhood vaccination coverage in rural Rwanda by improving access, awareness, and service delivery. Continued investment in CHW training, supervision, and logistical support is essential to sustain gains and achieve universal vaccination coverage by 2030.

➢ Open fractures are a critical global health challenge that disproportionately affect individuals in low- and middle-income countries (LMICs), primarily due to road traffic collisions. Surgical management of open fractures is 1 of the 3 essential bellwether procedures identified by The Lancet Commission on Global Surgery. ➢ We developed and evaluated a novel hybrid course on open fracture management for surgical trainees and practicing surgeons in Rwanda, combining a self-directed, virtual, pre-course curriculum with a live, in-person workshop in Kigali in June 2025 that was simultaneously live-streamed for virtual attendees. Prerecorded multilingual lectures (English and French) and curated peer-reviewed articles provided foundational knowledge in advance and prepared learners for in-person didactics, case discussions, and skills training. ➢ The in-person workshop included didactic sessions and discussions of local clinical cases from Rwanda related to open fracture management and other orthopaedic emergencies, along with hands-on practice in fracture external fixation and negative pressure wound therapy using affordable devices designed for resource-constrained practice. ➢ The workshop engaged 160 active learners (37 in-person, 123 virtual) and demonstrated high overall satisfaction among 84 survey respondents, with an average rating of 4.6 out of 5. ➢ Self-reported confidence in managing open fractures increased substantially following the course, from a mean rating of 3.83 to 4.69 on a 5-point scale (p < 0.001). Most survey respondents reported that the course moderately or significantly improved their knowledge (96.4%) and would change their clinical practice (96.5%). ➢ Participant feedback highlighted opportunities for improvement, including extending the workshop duration to increase hands-on time, expanding the content on complex soft-tissue management, and improving the engagement of remote learners through mechanisms such as the provision of low-cost external fixation models for at-home practice. ➢ Future directions include integrating the course into medical student and general practitioner education in Rwanda, adapting it for major surgical conferences regionally and internationally, and continuing to prioritize hands-on training modules. Iterative refinement of the course is planned on the basis of participant feedback.

Introduction: While philanthropy, multilateral support and innovative internal funding approaches remain important to address surgical healthcare needs, there is increasing demand for efficiency models that maximise the impact of available resources. Cost-saving strategies are attractive to governments. We sought to answer the scoping review question: ‘What are documented and transferable system-level cost-saving strategies in the provision of surgical healthcare services applicable in limited-resource settings?’ Methods: The scoping review was guided by the Arksey and O’Malley framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines; 642 studies were screened from PubMed, EMBASE, Global Index Medicus, Africa Journals Online and Google Scholar (2015–2024), without language or article type restrictions. Following title, abstract and full-text screening by 2 independent reviewers, we identified 63 records that met inclusion criteria: documented cost-saving strategies in surgical systems from community to national levels. Strategies were extracted into a theoretical framework adapted from the Procter and Gamble’s cost optimisation model and the Triple Aim Framework using Jabareen’s eight-step method. Results: Most literature on cost savings for surgical healthcare was from high-income countries (81%), at national levels (48%), and focused on orthopaedic/cardiothoracic/vascular surgery. Most (25%) were retrospective observational studies or economic modelling (21%). We synthesised 125 distinct cost-saving strategies into 32 transferable strategies across five thematic areas, prioritised using a sustainability and scalability lens—preventative healthcare management (9%), surgical healthcare guidelines and pathways (31%), payment model transformation (19%), lean principles (25%) and technology adoption (16%). Strategies focused on governance, standardisation and process redesign were more likely to be sustainable and scalable with minimal resources, whereas interventions requiring coordinated delivery models or advanced digital infrastructure were more scale-dependent Conclusions: We identified an integrated portfolio of contextualisable surgical cost-saving strategies that eliminate system waste, improve efficiency and result in savings. Policymakers and health system stakeholders in low-income and middle-income countries can use this structured evidence to prioritise, implement and scale cost-saving strategies.

Training the next generation of leaders in global surgery includes equipping learners with skills in collaboration, research, policy, and health system management. Since 2021, the Duke Global Health Institute and the University of Global Health Equity in Rwanda have co-taught a course in Global Surgical Care for learners from around the world. This review discusses our use of the Lancet Commission on Global Surgery (LCoGS), exploring it as both a foundational reference text and an organizing framework for teaching core issues in global surgical care. The LCoGS guides the selection of important topics including surgical disease burden, infrastructure, workforce, and economics. Through the semester, students use these concepts in team-based applications, culminating in the development of a National Surgical, Obstetric, and Anaesthesia Plan (NSOAP) for an assigned country. The LCoGS provides a valuable foundation for teaching global surgical priorities and analytic approaches and provides guidance to support advocacy, ethics, and contextualized implementation initiatives for training emerging global surgical leaders.

Road traffic crashes (RTCs) are a leading cause of morbidity and mortality in sub-Saharan Africa. This study describes the distribution and severity of RTCs across Rwandan districts, highlighting age- and sex-specific patterns. We conducted a retrospective analysis of national police-reported RTC data from 2015–2024. Quasi-Poisson regression was used to estimate relative risks (RRs) of specific crash outcomes by age, sex, season, and region, providing an assessment of demographic and geographic disparities. Crash severity indicators were defined as the proportion of each outcome relative to total annual crashes outcome. As findings, between 2015 and 2024, 51,984 RTC outcomes were reported, comprising 73.1% minor injuries, 14.4% serious injuries, and 12.4% fatalities. Males had 3 times higher risk of serious injuries and 5 times higher risk of fatalities than females. Adults aged 26–40 years had 13.4 times higher risk of serious injuries and over 6 times higher risk of death compared with children aged 0–5 years. Overall RTC severity declined by 77.6% (CI: 76.4%–78.9%) and fatalities by 50.6% (CI: 50%–51.2%), with (79%(CI:77.7%-80.7%) severity drops and 56.2%(CI:55.3%-57.4%) fatality drops in Kigali compared to (75.3%(CI:73.9%-77%) and 45.6%(CI:44.7%-46.7%) out of Kigali, respectively). The short rainy season was associated with a 68% higher risk of serious injuries and nearly double the risk of minor injuries compared with the dry season. RTC severity in Rwanda has declined substantially, yet young adults, men, rural travellers, and rainy seasons remain disproportionately affected. Targeted interventions are required to sustain progress and reduce disparities.

The field of global health is rooted in colonialism, and many global health partnerships perpetuate colonial power dynamics. To change this, knowledge and praxis in decoloniality must become a fundamental part of global health education and practice. Since there are no current tools in global health education specifically focusing on decolonial praxis, we drew on existing literature to develop a tool designed to measure a learner clinician’s progression in attitudes and practice regarding health equity and decoloniality. Milestones were defined across four learner levels: pre-contemplative, contemplative, critical action, and transformative action. Both a self-assessment and an educator assessment of a learner version of the tool were created. We conducted a modified Delphi process using an online survey to create consensus on 20 learner milestone definitions for this assessment tool. To craft a diverse Delphi panel, we invited 11 academic clinicians who have published at least one peer-reviewed publication surrounding decoloniality; six of whom were primarily based in a resource-denied setting, five of whom were primarily based in a resource-advantaged setting, and with at least one participant from sub-Saharan Africa, Central and South America, and Southeast Asia. Consensus was defined as >75% of panelists accepting the definition. After three rounds, Delphi members had reached consensus on all (20/20) items for both the self-assessment and educator assessment versions of the tool. Themes of changes to the tool included better reflecting the mutual learning that occurs between global partners, providing more observable behaviors for assessment, and incorporating transformative learning principles into the milestones, which predominantly utilize a behaviorist framework. This study provides consensus on milestone definitions for a learner assessment tool for clinician trainees in global health that allows learners and educators to engage in self-reflection and progression in decolonial attitudes and practice during an educational process.

Health researchers in the Global South face many barriers to scientific publication, including language limitations, lack of access to mentorship, and mini