Abstract
Healthcare workers commonly participate in cleft surgery programs to help address global disparities in access to care. The rigor of these programs varies considerably and may not be readily visible to prospective participants prior to engagement. We offer a practical framework to assist prospective volunteers in evaluating cleft surgery programs across domains of patient Safety, Continuity of care, organizational Accountability, Local workforce integration, and Equity and patient rights. The framework is intended for use prior to engagement in overseas clinical work and draws on the authors’ combined experience across multiple international cleft surgical programs.
Introduction
Cleft lip and palate affects approximately 1 in 700 live births globally and represents one of the most common congenital anomalies amenable to surgical correction. 1 The global backlog of untreated patients has made cleft lip and palate one of the most common conditions addressed by short-term surgical programs worldwide.2,3 In many low- and middle-income countries, access to surgery and comprehensive care remains severely limited. 4 Surgical programs have long played a role in attempting to address this gap, providing operative intervention where local capacity is absent or insufficient.
Most cleft surgical programs are designed around what visiting teams can deliver within a fixed period, yielding outcomes that are visible and communicable. This model reflects the reality of volunteer availability: most clinicians can offer weeks per year, not months. It also establishes a tendency to prioritize immediate service delivery over the prolonged responsibility that surgery creates.
It is worth being explicit about what this means in practice: a primary lip repair and a primary palate repair are not equivalent in their management ramifications. A well-performed lip repair is a relatively self-contained intervention, with the immediate outcome visible, the complication rate low, and while follow-up matters, the adverse sequelae are more limited.
Dental and orthodontic follow-up, while an important component of comprehensive cleft care, is similarly more limited in its immediate consequences if unavailable, and represents a longer-term aspiration for program development rather than an acute obligation.
Palate repair is categorically different. Velopharyngeal insufficiency, palatal fistula and the need for revision surgery are consequences that need to be monitored longitudinally. Managing these outcomes should ideally be achieved within a multidisciplinary setting with available speech therapy, specialist surgical input and documentation of patient care.5,6 In many of these countries, however, these standards are simply not achievable due to barriers in the health system as well as patient factors.
For clinicians considering participation in cleft surgical programs, the structural characteristics of a program are not easily visible or contemplated. Healthcare workers frequently rely on organizational reputation or peer endorsement when selecting opportunities, with limited insight into how care is delivered prior to a team's arrival and once visiting teams depart.
We propose the Safety, Continuity of care, organizational Accountability, Local workforce integration, and Equity and patient rights (SCALE) framework to assist prospective volunteers in evaluating program characteristics that align short-term service delivery with longer-term responsibility, prioritizing local health system strengthening within any well-intentioned surgical initiatives.
The SCALE Framework for Evaluating Global Surgical Programs
The SCALE framework highlights priorities for global surgical programs and provides practical questions to guide due diligence prior to engagement. It is intended to assist healthcare workers to appraise the responsibility of the structure within which they will be working.
Safety
Safe surgery depends not only on technical skill, but on systems of accountability. In global settings, outcome tracking, complication reporting, and peer review processes may be inconsistent or absent. In some surveys, volunteers have reported practicing outside their routine scope when abroad, and not all organizations maintain structured credentialing processes. 7 Clarity on how clinical governance is maintained and how volunteer skill sets are verified is central to understanding program safety.
Key considerations:
- Are peri-operative outcomes tracked? - Are complications formally reviewed or analyzed? - Are recognized safety protocols (eg, WHO Surgical Safety Checklist) consistently applied? - Do volunteers work within their home scope of practice? - Are volunteers appropriately credentialed and verified prior to deployment?
Continuity of Care
Surgery creates an obligation that extends beyond the operative period. Surveys of programs have demonstrated that postoperative review often ends within days of surgery, despite complications that may arise weeks later. 8 In some settings, local surgeons report managing secondary corrective procedures following complications from visiting teams, underscoring the inadequacy of short-term follow-up.9,10
In many instances, responsibility for postoperative care defaults to local providers once visiting teams depart, frequently in the absence of formal transfer of care or defined follow-up pathways. The absence of continuity risks leaving patients and local teams to manage complications without adequate support. Understanding how this is operationalized once external teams withdraw is central to evaluating program structure.
Key considerations
- Is there a defined postoperative follow-up pathway? - Who is responsible for managing complications after departure? - Are patient records accessible to local providers? - Are patients supported if additional surgery or complication management is required? - For programs with repeat visits, is there a mechanism for reviewing outcomes from prior visits?
Accountability
Unlike hospitals in high-income settings, short-term programs may operate without external regulatory oversight. 11 The distinction between short-term service delivery and longer-term educational investment has been well described in related surgical specialties. 12 Governance structures, financial transparency, and formal quality review processes vary considerably between organizations. Ethical dilemmas may arise in relation to supply management, data reporting, or use of equipment.
How the organization governs itself and maintains accountability is a defining feature of program structure.
Key considerations
- Is it clear who is responsible for how the program is run, including clinical oversight and decision-making? - Are finances publicly reported or otherwise transparent? - Are program outcomes audited or externally reviewed? - Does the organization comply with local licensing and regulatory requirements? - Is there a defined long-term strategy? - Are supplies and equipment managed in a way that supports local sustainability?
Local Workforce Integration
Short-term clinical delivery may address immediate surgical need but does not necessarily build sustainable capacity.13,14 If visiting teams perform procedures without integrating local staff, opportunities for relationship building, workforce development, and learning exchanges informed by local knowledge may be missed.
Meaningful engagement with local providers should begin prior to program delivery. Participation in clinical activity without first understanding locally led priorities, cultural context, or existing care pathways may limit the relevance and sustainability of well-intentioned efforts.
In many settings, the clinicians best positioned to lead this integration are those who have made a deliberate commitment to their home communities. Identifying and supporting these local champions, and structuring programs around their priorities, is among the most consequential contributions a global surgical program can make.
Programs that prioritize meaningful inclusion of local providers, structured teaching, mentorship, and progressive transfer of responsibility are more likely to contribute to long-term system strengthening.
Key considerations
- Was the program developed in collaboration with local healthcare providers? - Are local staff involved in program delivery, with opportunities for training or skills development? - Are local providers progressively assuming greater responsibility over time? - Does the program strengthen existing services rather than operate in parallel to them?
Equity and Patient Rights
Language barriers, cultural differences, and fundraising practices introduce additional ethical complexity.15,16 Informed consent processes may be compressed in high-volume settings. The use of patient images for publicity or fundraising requires explicit and comprehensible consent, obtained separately from consent for clinical intervention. A useful standard is to ask whether the same image, taken under the same circumstances, would be permissible in the volunteer's home institution.
Patient dignity, autonomy, and equitable access to follow-up care depend on how these principles are embedded within program design.
Key considerations
- Is informed consent obtained in a language the patient understands? - Is consent for image use obtained separately from consent for clinical intervention, with clear explanation of intended use? - Are patient confidentiality and dignity respected, including appropriate use of images? - Are volunteers bound by a clear code of conduct?
Discussion
Short-term global surgical programs often sit at the intersection of 2 impulses: the desire to relieve immediate suffering, and a responsibility to ensure continuity of care. The first intention is easier to achieve than the second.
Short-term clinical engagement allows visiting teams to address visible needs quickly. However, surgery is not a discrete act. It initiates a longitudinal obligation that extends beyond the period of direct involvement of the volunteer team. Postoperative complications, delayed wound breakdown, functional impairment, or the need for revision procedures may emerge months or years after initial treatment. In the absence of structured follow-up pathways, responsibility for these outcomes is frequently transferred to local providers who may not have participated in the index procedure or may lack the resources or time required for subsequent management.
A useful way to understand this is to consider the organization as defining the structure within which care is delivered. Volunteers work within that structure, but cannot meaningfully alter it during a short deployment. Where there is no provision for follow-up, no integration with local providers, and no plan for ongoing care, these gaps persist regardless of the intentions or skill of the visiting team. Responsibility for how care is ultimately delivered therefore lies primarily with the program design.
The SCALE framework is intended to support prospective evaluation of these structural characteristics by healthcare workers prior to engagement. It is not an accreditation instrument, nor does it assume that programs lacking formal structures are without value. Rather, it seeks to make explicit the features that determine how care is sustained beyond the operative encounter, and to prompt more informed dialogue between prospective volunteers and program leadership.
The contribution of a program should ultimately be judged by what it leaves behind: in clinical outcomes, in local capacity, and in the conditions for ongoing care. Short-term volunteer activity, when embedded within a structure that recognizes these responsibilities, remains a valuable component of cleft care in resource-constrained settings.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Appendix: The SCALE Checklist for Evaluating Cleft Surgery Programs
This checklist is intended to assist prospective volunteers in conducting structured due diligence prior to participation in a cleft surgery program. It is written for all members of the visiting team, clinical and nonclinical alike. It may also be used by program leaders for self-assessment.
S—Safety
Question
Yes
No
Comments
Does the program track surgical outcomes (eg, complications, wound healing) beyond the immediate operative period?
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□
Are complications formally reviewed or analyzed (eg, audit, morbidity and mortality process)?
□
□
Are recognized safety protocols (eg, WHO Surgical Safety Checklist, sterility standards) consistently applied?
□
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Do volunteers work within their established scope of competence?
□
□
Are volunteers appropriately credentialed and their relevant experience verified prior to deployment?
□
□
C—Continuity of Care
Question
Yes
No
Comments
Is there a defined postoperative follow-up pathway, delivered by identified local providers?
□
□
Who is responsible for managing complications after the visiting team departs, and is this formally communicated?
□
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Are patient records transferred to local providers in a usable and accessible format?
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Are patients supported if additional surgery or complication management is required?
□
□
For programs with repeat visits, is there a mechanism for reviewing outcomes from prior visits?
□
□
A—Accountability
Question
Yes
No
Comments
Is there clear organizational leadership with defined clinical oversight and decision-making responsibility?
□
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Are program finances publicly reported or otherwise accessible to stakeholders?
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Are program outcomes audited or externally reviewed, and are results available?
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Does the organization comply with local licensing and regulatory requirements in-country?
□
□
Is there a defined long-term strategy?
□
□
Are supplies and equipment managed in a way that supports local sustainability rather than dependency?
□
□
L—Local Workforce Integration
Question
Yes
No
Comments
Was the program developed in collaboration with local health care providers?
□
□
Are local staff involved in program delivery, with opportunities for training or skills development?
□
□
Are local providers progressively assuming greater responsibility over time?
□
□
Does the program strengthen existing services rather than operate in parallel to them?
□
□
E—Equity and Patient Rights
Question
Yes
No
Comments
Is informed consent obtained in a language the patient or guardian understands, with adequate time for questions?
□
□
Is consent for image use obtained separately from consent for clinical intervention, with a clear explanation of intended use?
□
□
Are patient confidentiality and dignity respected throughout screening, operative and postoperative phases?
□
□
Are volunteers bound by a clear code of conduct?
□
□