BMJ Open 1:e000166 doi:10.1136/bmjopen-2011-000166
  • Surgery
    • Protocol

Implementing surgical services in a rural, resource-limited setting: a study protocol

  1. Selwyn Rogers6
  1. 1Nyaya Health, Bayalpata Hospital, Ridikot VDC, Achham, Nepal
  2. 2Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3School of Medicine, Yale University, New Haven, Connecticut, USA
  4. 4School of Medicine, Brown University, Providence, Rhode Island, USA
  5. 5Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
  6. 6Department of Surgery and the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
  7. 7Division of Health Sciences, Montana State University, Bozeman, Montana, USA
  1. Correspondence to Jesse Stark Brady; jesse{at}
  • Received 11 May 2011
  • Accepted 5 July 2011
  • Published 4 August 2011


Introduction There are well-established protocols and procedures for the majority of common surgical diseases, yet surgical services remain largely inaccessible for much of the world's rural poor. Data on the process and outcome of surgical care expansion, however, are very limited, and the roll-out process of rural surgical implementation in particular has never been studied. Here, we propose the first implementation research study to assess the surgical scale-up process in the rural district of Achham, Nepal.

Methods and analysis Based primarily on the protocols of the WHO's Integrated Management for Emergency and Essential Surgical Care (IMEESC), this study's threefold implementation strategy will include: (1) the core IMEESC surgical care program, (2) community-based follow-up via health workers, and (3) hospital-based quality improvement programs. The implementation program will employ additional emergency and surgical care protocols developed collaboratively by physicians, nurses and the authors. This strategy will be referred to as IMEESC-Plus. This study will employ both qualitative and quantitative research methodologies to collect clinical data and information on the reception and utilisation of services. The first 18 months of the implementation process will be studied and divided into an initial phase (first 6 months) and a consolidation phase (subsequent 12 months).

Discussion This study aims to describe the logistics of the implementation process of IMEESC-Plus, and assess the quality of the resulting IMEESC-Plus services during the course of the implementation process. Using data generated from this study, larger, multi-site implementation studies can be planned that assess the scale-up of surgical services worldwide in resource-limited areas.


  • To cite: Maru DS-R, Schwarz R, Schwarz D, et al. Implementing surgical services in a rural, resource-limited setting: a study protocol. BMJ Open 2011;1:e000166. doi:10.1136/bmjopen-2011-000166

  • Funding Duncan Maru is supported by the Global Health Equity fellowship program within the Department of Medicine at Brigham and Women's Hospital.

  • Competing interests None.

  • Ethics approval An IRB proposal has been submitted to Brigham and Women's Hospital.

  • Contributors DM, RS, DS, JA, MP and SR worked together to conceive the study and develop the methodology. JB and GK helped to refine the methods and draft the manuscript. All authors read and approved the final manuscript.

  • Provenance and peer review Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

blog comments powered by Disqus