S.C.A.L.P.E.L. for global surgery: Rethinking surgical outreach as true capacity-building

Surgical outreach is on the rise in global surgery, with the United States alone sponsoring more than 2000 trips annually to the Global South to help address the mismatch in per capita surgical cases to per capita surgeons. ¹ But, what good is a fly-in, fly-out surgical mission if, after the visiting team departs, the local community remains just as dependent as before? For decades, surgical outreach programmes from high-income countries (HICs) have been celebrated for providing thousands of operations in resource-limited settings. Yet the question must be asked: do these trips cure dependency or perpetuate it? The answer lies in whether they prioritise surgical capacity-building, that is, equipping local systems, professionals and communities to deliver safe, timely and affordable surgery long after the visitors are gone.

Outreach as capacity-building: The paradigm shift

Short-term surgical trips once focused almost exclusively on service delivery. They provided a burst of care but often left gaps in continuity, overburdened fragile systems and, at times, disempowered local providers. Their motivation is their own ‘feel good factor’.

True impact, however, requires a shift to capacity-building with emphasis on training, sustainability and system strengthening. Despite the publication of guidelines as long ago as 2013, ² these have not been heeded (Table 1).

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Table 1.

Comparison between mission trips and capacity-building in surgical outreach.

Dimension	Old-style mission trips	Capacity-building outreach
Primary focus	Short bursts of service delivery (high case volume in a few days)	Training, mentorship and systems strengthening
Agenda setting	Visiting team defines priorities, often with minimal local input	Jointly developed, reflecting local needs and ownership
Skills transfer	Limited or absent; visiting surgeons perform the majority of cases	Emphasis on knowledge transfer and mentorship; local teams perform and teach
Continuity of care	Little follow-up once visiting team departs	Local providers ensure ongoing care and follow-up
Impact on dependency	Can foster reliance on visiting teams	Builds self-reliance and reduces long-term dependence
System burden	May strain local staff and resources with sudden influx of cases	Strengthens infrastructure, supply chains and workforce
Sustainability	Episodic, dependent on external funding and teams	Long-term outcomes through local leadership and resilient systems

The Global-QUEST framework usefully defines seven domains of surgical capacity-building on surgical outreach trips (Table 2). ³ We propose a mnemonic to capture the core contributions of HIC outreach when done right:

Skills transfer (professional development)

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Table 2.

S.C.A.L.P.E.L. framework for surgical capacity-building.

	Meaning in S.C.A.L.P.E.L.	Domain in Global-QUEST		Practical contribution of outreach programmes
S	Skills transfer	Professional development		Training local health care workers, mentorship, simulation-based teaching and train-the-trainer models that create multiplier effects.
C	Collaboration	Partnership and coordination		Building long-term, bi-directional partnerships; aligning with local needs and surgical plans; coordinating logistics and academic exchange.
A	Accountability	Governance		Respecting local regulations, working under national surgical plans, ethical oversight and monitoring/evaluation of outreach impact.
L	Local Leadership	Leadership		Empowering local champions, supporting indigenous training institutions, fostering research capacity and reducing ‘brain drain’ by strengthening career pathways.
P	Platforms for sustainability	Finance and infrastructure		Supporting infrastructure (equipment, OR capacity, supply chains), tapering external funding and promoting local resource mobilisation.
E	Empathy and cultural respect	Culture		Honouring local norms, languages and values; fostering epistemic justice by integrating local knowledge.
L	Lasting impact	Community impact		Needs assessments, long-term follow-up, outcome monitoring and leveraging digital platforms (e.g. SURGhub) for sustained learning and care.

S: Perhaps the most powerful contribution of outreach is the transfer of surgical skills. A single well-trained surgeon may directly treat 10,000 patients over a whole career. But if trained as an educator, the lifetime impact, through successive generations of trainees, can exceed 400,000 treated. ⁴

C: Capacity-building thrives when partnerships are bidirectional and sustained. Too often, guidelines and training modules have been authored without meaningful input from local stakeholders. Such unilateralism risks reinforcing dependency rather than dismantling it. Examples such as the College of Surgeons of East, Central and Southern Africa illustrate the power of collaborative training models where HIC institutions partner with regional colleges but local leadership drives design and implementation. ⁵ Effective outreach programmes must embed themselves in local ecosystems – not as saviours, but as partners walking alongside.

A: Without accountability, outreach risks unintended harm: inappropriate procedures done, poor follow-up and over-burdening fragile systems. Governance structures, involving clear agreements with host ministries, ethical oversight and alignment with national surgical plans are critical. ⁶ Guidelines stress that visiting teams must not practice outside their scope and must comply with local regulations. Moreover, rigorous monitoring and evaluation are non-negotiable. Surgical outreach cannot be a free-for-all; it must model responsible professionalism and submit to the same accountability demanded of local practitioners.

L: Capacity-building must be cultivated locally. Outreach programmes should identify and empower local champions, supporting them to assume leadership in training, governance and research. This enhances retention. ⁷

P: Financial dependence on external donors is a fragile foundation. Effective outreach must support host institutions to reduce reliance on visiting teams by investing in infrastructure, supply chains and local funding mechanisms. For example, Kids Operating Room has installed paediatric operating rooms, trained workforce and addressed critical gaps in over 35 low- and middle-income countries with the aim of bringing access to safe surgery to every child who needs it. ⁸ Targeted training in Vietnam translated into an 81% increase in surgical volume within five years, independent of visiting teams. ⁹

E: No surgical partnership can thrive without deep cultural humility. Outreach must honour local norms, languages and values. When visitors fail to adapt, they risk alienating communities and undermining local providers. Respect is more than etiquette: it is epistemic justice. It recognises that local knowledge is not inferior but essential. Embedding cultural competence into outreach programmes ensures they are welcomed, trusted and contextually relevant.

L: Ultimately, the measure of success is not how many operations were performed during a visit, but how lives and systems were improved after the team has left. Therefore, planning needs assessments, outcome monitoring and iterative engagement to create lasting impact rather than episodic relief to a select few.