Expanding Cleft Surgical Workforce Capacity in Low- and Middle-Income Countries Through Competency-Based Training

Abstract

Objective To evaluate a competency-based cleft surgery training pathway designed to expand local surgical capacity in low- and middle-income countries (LMICs). Design Prospective observational study of cleft surgery training outcomes between July 2022 and September 2024. Setting Operation Smile cleft surgery programs and partner hospitals in LMICs, with integrated virtual education. Patients/Participants Twenty trainee cleft surgeons from 11 countries. Interventions A competency-based training pathway combining virtual education and mentored operative experience, with assessment using a validated surgical competency tool. Main Outcome Measures Changes in self-reported surgical confidence and educator-rated surgical competency Results Trainee cleft surgeons participated in 1168 cleft lip and palate repairs, including 862 primary procedures. Confidence improved significantly for all primary procedures (unilateral cleft lip (UCL) P = .001; bilateral cleft lip P < .001; cleft palate P < .001), with greatest gains in cleft palate repair. Educator-rated competency increased by 46% for UCL, 56% for bilateral cleft lip, and 71% for cleft palate repair. By September 2024, 3 surgeons had completed the pathway; by April 2025, 8 had completed training, with others progressing toward certification. Conclusions Competency-based cleft surgery training in LMICs, delivered through partnerships between non-governmental organizations and local health systems, improves surgical confidence and competence while maintaining local workforce integration. Combining high-volume operative experience with structured education offers a scalable model to expand workforce capacity and support sustainable, locally led cleft care. Long-term success depends on developing systems capable of sustaining training and service delivery independently.