A review of practices and policies of international humanitarian organizations in conflict-affected settings: are we ensuring sustainability of surgical care?

International humanitarian organizations providing surgical care in conflict-affected settings have an ethical obligation to adopt practices that promote sustainable surgical services. Our objective was to evaluate the prevalence of sustainable surgical practices and policies implemented by humanitarian organizations in conflict-afflicted settings, as well as to document instances where surgical services were disrupted or discontinued due to the outbreak of conflict.

A review of primary literature was conducted using Medline. Articles were included if they described sustainable surgical practices or policies in conflict-affected settings. Sustainability was defined according to a previously published modified Delphi consensus framework, which outlined key pillars of sustainability in global surgery partnerships. A grey literature review was also performed to identify sustainable policies published by international humanitarian organizations on their online platforms.

Of 1,057 articles screened, 29 articles met inclusion criteria, describing 54 surgical programs implemented by 17 international humanitarian organizations —most commonly Médecins Sans Frontières (n = 27) and International Committee of the Red Cross (n = 5). These programs were implemented in 36 conflicts between 1946 and 2023, most commonly in Sub-Saharan Africa (n = 20), the Middle East (n = 11), and Southeast Asia (n = 9). The following six sustainability pillars were explicitly described: context-relevant education (94.4%), multidisciplinary involvement (74.1%), outcome measurement (72.2%), stakeholder engagement (66.7%), handover to local stakeholders (18.5%), and multisource funding (13.0%). Escalating violence led to permanent closure of 13.0% of programs and led to service interruptions in 9.3%. The mean duration of programs was 9.5 ± 9.7 years. Publicly available policies were identified for six organizations (35.3%), and all but one organization captured every aforementioned pillar of sustainability.

International humanitarian organizations have increasingly adopted sustainable practices and policies when delivering surgical care in conflict-affected settings—most notably in the area of context-relevant training. We encourage global actors to continue prioritizing this domain, especially in fragile states where service cessation or interruptions can occur at any time, necessitating sustainable surgical care delivered by trained local physicians. This review highlights exemplary practices documented in the literature and offers insights into how global surgery partners can build on existing efforts.