Policy options for surgical mentoring: Lessons from Zambia based on stakeholder consultation and systems science

Abstract

Background Supervision by surgical specialists is beneficial because they can impart skills to district hospital-level surgical teams. The SURG-Africa project in Zambia comprises a mentoring trial in selected districts, involving two provincial-level mentoring teams. The aim of this paper is to explore policy options for embedding such surgical mentoring in existing policy structures through a participatory modeling approach. Methods Four group model building workshops were held, two each in district and central hospitals. Participants worked in a variety of institutions and had clinical and/or administrative backgrounds. Two independent reviewers compared the causal loop diagrams (CLDs) that resulted from these workshops in a pairwise fashion to construct an integrated CLD. Graph theory was used to analyze the integrated CLD, and dynamic system behavior was explored using the Method to Analyse Relations between Variables using Enriched Loops (MARVEL) method. Results The establishment of a provincial mentoring faculty, in collaboration with key stakeholders, would be a necessary step to coordinate and sustain surgical mentoring and to monitor district-level surgical performance. Quarterly surgical mentoring reviews at the provincial level are recommended to evaluate and, if needed, adapt mentoring. District hospital administrators need to closely monitor mentee motivation. Conclusions Surgical mentoring can play a key role in scaling up district-level surgery but its implementation is complex and requires designated provincial level coordination and regular contact with relevant stakeholders.

Using network analysis to identify leverage points based on causal loop diagrams leads to false inference

“…The problems with the use of betweenness-and closeness centrality to identify "structurally important nodes" 66 are far from unfamiliar, where many of the problems previously detected in other fields 61 also apply to CLDs and several papers applying network analysis metrics to CLDs also hint at potential limitations 8,23,24,26,28,[36][37][38]42,52 . It has already been shown for different types of networks that betweenness-and closeness centrality do not provide reliable results over networks that differ slightly in structure, for example when a node is included or excluded 61,69,70 .…”

“…Challenges regarding the specification of boundaries-i.e., which nodes should be included in and excluded from the network-which critically affects betweenness-and closeness centrality results, have accordingly also been extensively discussed in other fields 69,74,75 . This and other bodies of literature do not seem to have been considered in research using CLDs, presumably because, even though network analysis metrics are being applied, CLDs are not typically thought of as analysable as networks, with many papers that apply www.nature.com/scientificreports/ network analysis metrics to CLDs first providing some type of justification for why a CLD could be interpreted as a network (e.g., 8,[23][24][25][27][28][29][30]37,42,43,47,50,54 ).…”

“…In seeking alternative methods, network analysis 35 has gained momentum as an accepted practice to quantitatively identify leverage points based on CLDs 8 , 23 – 30 , 36 – 55 —for example in public health 24 , 38 , 45 , 50 , 52 , 53 , 55 . Here, 22 of the 29 papers that we identified that adopt this practice were published in 2021 (4 papers 23 , 25 , 37 , 50 ), 2022 (8 papers 27 , 28 , 43 – 45 , 47 , 49 , 52 ), and 2023 (10 papers to date 26 , 30 , 36 , 38 , 39 , 41 , 42 , 46 , 53 , 55 ). Network analysis seemingly has the potential to mathematically analyse a CLD, which in this context can be considered a network of factors, to systematically find which factors represent leverage points.…”

“…In seeking alternative methods, network analysis 35 has gained momentum as an accepted practice to quantitatively identify leverage points based on CLDs 8,[23][24][25][26][27][28][29][30][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55] -for example in public health 24,38,45,50,52,53,55 . Here, 22 of the 29 papers that we identified that adopt this practice were published in 2021 (4 papers 23,25,37,50 ), 2022 (8 papers 27,28,[43][44][45]47,49,52 ), and 2023 (10 papers to date …”

Systems Science and Evidence-Informed Deliberation to Mitigate Dilemmas in Situations of Dual Agency at the Hospital Level Comment on "Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations"

“… 8 In our own study in Zambia, which involved a series of participatory action research workshops and dynamic modelling, we explored policy options for embedding a surgical mentoring initiative into Zambia’s national health policy. 9 Admittedly, systems science is quite different from the method employed in the present paper, but given the nature and importance of the topic at hand it might be of future use to shed further light on the challenges and dilemmas that health professionals with dual agency face in their decision-making.…”