Kigali — "Surgery is a fundamental and necessary aspect of healthcare. Surgery is attributed to approximately 30% of the global disease burden. However, for many years, the global health agenda has been centered on individual diseases, resulting in surgical care receiving the least attention," said Professor Faustin Ntirenganya, President of the Rwanda Surgical Society.
Ntirenganya was speaking at the Pan-African Surgical Conference in Rwanda under the theme of Building Resilient and Sustainable Surgical Services in Africa.
The African continent is projected to lack over six million surgical care providers by 2030, with most countries averaging about 0.5 surgeons and 0.1 anesthetists per 100,000 people. Rwanda currently has 162 surgeons, far below the standard of 1,400, and only 0.9 surgical theaters per 100,000 population.
Millions of people around the world are without access to life-saving surgical care, which Professor Ntirenganya described as a "fundamental human right".
He said while Rwanda is widely known for its scenic landscapes, a country of a thousand hills with beautiful mountain gorillas, and beautiful wildlife, he preferred to introduce it as a nation with significantly reduced maternal, neonatal, and under-five mortality rates.
Professor Ntirenganya recalled Rwanda's genocide in 1994, which devastated its infrastructure, including its healthcare system. The country began rebuilding in early 1995, but healthcare services were non-existent. Rwanda launched its first general surgery residency program in the early 2000s. The Rwanda Surgical Society, which Professor Ntirenganya represents, was established in 2007, marking an important step forward in surgical training and regional collaboration.
"That's when the process happened here in Rwanda in 2008. And further, surgery continued developing, and we started growing in terms of training programs and subspecialties, like the one I like most, plastic surgery, which came into this country at that time," he said.
Ntirenganya said Rwanda adopted a new strategy, the 4x4 strategy, aimed at increasing both the quantity and quality of healthcare professionals, including surgeons in the country within the next four years to meet the WHO recommendation of at least four healthcare professionals per 1,000 population density. In the 4x4 reform, the health sector will grow its pool of health professionals, including residents, fellows, general practitioners, dentists, pharmacists, nurses, and midwives. The ambitious plan aims to increase the health workforce by 32,973 employees by 2028.
This strategic initiative builds upon the groundwork laid out in the National Strategy for Health Professionals Development (NSHPD) 2020-2030 and aligns with the Ministry of Health's Strategic Priorities 2023-2025, which aim to improve primary healthcare systems and public health security by promoting evidence-based medicine, enhanced leadership, and digital integration approaches, among other things.
Ntirenganya hopes community health workers will soon contribute to surgical care, even though surgery is fully integrated into the system. Rwanda performs "a little bit okay" on global surgical indicators, but certain areas need improvement. Rwanda's surgical community and infrastructure are severely understaffed. The country has only three hypo-anesthesia professionals for its 14 million residents, far below the recommended 20. The country performs around 1,788 surgeries per year, whereas the global standard recommends 5,000 surgeries per 100,000 people.
"Rwanda has 162 surgeons. But if we go by standards, we should be having around 1,400. This is a huge gap. It's maybe 10 times less than what we should be having," he said. "As of today, 46% of the surgeons are located in tertiary hospitals and 28% are in private hospitals. Since most of these facilities are in Kigali, only 26% of surgeons serve communities outside the capital, making access to care more difficult."
The problem is further compounded by limited infrastructure, simulation training facilities, and access to intensive care units (ICUs).
He said there's a need for advanced surgical tools such as microsurgery, minimally invasive surgery, and robotic surgery to keep up with global standards. These technologies, however, are currently unavailable in Rwanda due to a lack of access and maintenance.
Dr. Sabin Nsanzimana, Rwanda's Minister of Health also spoke about the significant gap in the number of surgeons in Rwanda, saying that while the country currently has only 162 surgeons, it needs 1,000. Despite the challenge, he expressed optimism, citing the recent increase in surgical residency enrollments from three to over 60 students annually.
Dr. Nsanzimana urged young doctors to consider careers in surgery, critical care, and emergency medicine, pointing out that while artificial intelligence will transform many medical fields, "there's only one area that's not going to be touched by AI, and that is surgery." AI can assist surgeons, he said, but "you can't develop an algorithm to cut, suture, and remove without a surgeon's presence."
Ntirenganya said the country faces a range of surgical care challenges, with human resources being the most pressing. "We are not only short on surgeons. We also lack anesthesia providers, nurses, and biomedical engineers," he said. The shortage extends to "limited spaces and infrastructure" and "not enough simulation rooms" to train surgeons before operating on real patients. He also shared plans to expand training sites to provincial and district hospitals, bringing surgical training closer to communities in need.
"We cannot just be left behind."
Despite the challenges, Ntirenganya said there are significant opportunities, such as government support at the highest level, including a commitment from the president to address the issues.
"We now have 144 trainees across different specialties, from general surgery to orthopedics," he said. However, he cautioned that traditional methods alone would not be enough to close the gap, warning, "If we continue in the traditional way, it may take us hundreds of years to catch up."
"Another opportunity that we have is that the country has been able to invest in health," he said. The country has invested heavily in healthcare infrastructure, including drone-based blood distribution systems, efficient ambulance services, and the construction of modern hospitals. The Rwandan government announced plans to renovate over ten district hospitals as part of its effort to improve healthcare services.
In his address, Professor Ntirenganya laid out Rwanda's strategies for advancing surgical care, calling out the importance of aligning initiatives with national priorities. To ensure sustainability, he said the importance of a holistic approach, addressing the "five S's": staff, stuff, space, services, and systems.
"That's why we are gathering today so that we can borrow different ideas from you and try to implement it," he said. "But we try to do all of this with love and smile."
He also said there's a need for comprehensive planning, including long-term goals like Rwanda's 2050 goals and cyclical plans to ensure deliberate and structured progress. The national surgical plan expired in December and is being revised to align with new national strategies. "We are in the process of developing a new one so that we can also align with the new national strategy," said Professor Ntirenganya. "We have to have in that plan improved targets and improved mechanisms to support its implementation. We also want to accelerate capacity building."
He said the importance of scaling up training programs while ensuring quality, saying that the worst outcome would be having surgeons who cannot operate effectively.
"A surgeon must be able to operate, so the quantity should not overshadow the quality."
"But as a vision of Rwanda surgery, we aspire to build a resilient and sustainable surgical system, providing quality surgical care and special training, driving impactful change in Rwanda, Africa, and beyond. Surgery in Rwanda is promising, it is coming from afar, going so far, but fortunately, we know where we are going."
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He concluded by reaffirming that access to life-saving surgical care is a fundamental human right, and Rwanda is committed to providing the best surgical services for its people.
Surgery is not a luxury
Dr. Édouard Ngirente, the Prime Minister of Rwanda expressed his honor to represent President Paul Kagame at the conference, calling attention to the importance of addressing surgical care challenges in Africa.
"Surgery is not a luxury. It is not a pillar of healthcare. Yet 70% of the world's population lack access to safe, timely, and affordable surgical care," he said.
Dr. Ngirente said that the disproportionate burden Africa faces, with 21% of the world's disease burden but only 2% of the global healthcare workforce, leading to daily loss of lives. He outlined Rwanda's efforts to improve surgical care, including expanding teaching hospitals in rural areas to train surgeons closer to the communities they serve.
"Our aim is to ensure that the next generation of surgeons is trained in settings that are geographically accessible to the populations that need them most. A tangible success story of this effort has been our partnership with Operation Smile. Through this cooperation, we have observed notable progress in our plastic and reconstructive surgery workforce," he said.
He called for innovation in surgical education, telemedicine, and research to build safer surgical ecosystems across Africa. He commended Operation Smile's partnership for advancing plastic and reconstructive surgery and IRCAD Africa's partnership, a global organizing center for surgical training and innovation to train African surgeons in minimally invasive and robotic surgery.
"This partnership has also demonstrated how investments in healthcare services can drive sustainable change, not only in Rwanda but also across the continent. Therefore, this conference must be a catalyst for action, not just another meeting," said Dr. Ngirente.
