Closing the knowledge gap in paediatric surgery: An implementation science approach using the SPACES-ECHO programme

Principal Investigator: Dr Rocco Friebel

Research Snapshot: Closing the knowledge gap in paediatric surgery in Somaliland

This implementation science project explored the impact of the Somaliland Paediatric Access and Clinical Excellence in Surgery - ‘Expanding Community Healthcare Outcomes’ (SPACESECHO) programme in Somaliland.

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What did the study set out to achieve?

Children in Somaliland face high rates of preventable illness and mortality due to limited access to safe paediatric surgical care. Given the shortage of specialists, children are often treated by general surgeons, general physicians and non-physician clinicians. Capacity of surgical providers is low, with limited opportunities for training of specialists. Enhancing specialist knowledge within the existing health workforce is a priority, and telemedicine can provide tailored learning opportunities.

A mixed-methods evaluation was conducted, to assess the value of the ECHO programme and the community outreach for healthcare professionals and children under 16 years old. This included tracking engagement with the training programme, surveys to assess knowledge gains and satisfaction, and focus groups to explore participation drivers and barriers. Clinical outcomes for children treated across seven hospitals were also collected.

What were the key findings?

• Twenty ECHO training sessions were delivered between December 2023 and September 2024, engaging 223 participants: predominantly male general physicians.  
• Participants showed moderate knowledge gains, with greatest improvement (12%) in pre/peri-operative care, strong for a short virtual course.
• The programme was viewed as valuable, relevant, and feasible. Demand was driven by opportunities to build knowledge, share experiences, and collaborate with others.  
• Although initial engagement was strong, attendance declined over time. Most participants attended between 2-5/20 sessions. Barriers to participation included workload and competing commitments, internet/platform challenges, and session timing.  
• ECHO strengthened clinical capacity and knowledge. Participants reported that burn cases could be managed locally in district hospitals rather than being referred.  
• The linked community outreach and support groups improved awareness, health seeking behaviours, household reach, and caregiver confidence.

What does this mean for policymakers and practitioners?

Tele-mentoring shows strong potential as an accessible approach for engaging medical professionals and building clinical capacity. Its wider implementation could be integrated into national continuing medical education frameworks, with policymakers formally recognising tele-mentoring as a valid mode of professional development linked to career progression incentives.  

However, barriers to participation must be addressed. Policymakers should ensure training can be prioritised within workloads, with mandatory participation considered to support consistent engagement. To ensure sustainability and greater impact, programme leadership should gradually transition to Somaliland’s health institutions, strengthening local ownership and alignment with national health priorities. In the short term, partner funding and technical support would be needed to enable this transition.

Investment in digital infrastructure and skills is also essential. Connectivity remains limited in remote areas, and digital literacy varies among professionals. Until coverage improves, offline training options should be maintained alongside targeted digital literacy training. Finally, aligning community mobilisation with service delivery should continue, supporting health literacy and encouraging greater uptake of hospital services.

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