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What is humanitarian surgery?

To help achieve an international consensus on what ‘humanitarian surgery’ is, we will undertake a modified Delphi process involving stakeholders around the world. 

Global surgery or humanitarian surgery

Over the last decade, there has been an exponential increase in the usage of ‘global surgery’ and ‘humanitarian surgery’ in publications. However, the terms are often used interchangeably and there is no fixed definition of humanitarian surgery. This makes it difficult to compare interventions, outcomes and cost-effectiveness since a wide variety of activities are included in these global or humanitarian surgery programmes.

To address this question, a modified Delphi process will be used, drawing on experts from across the world. The respondents will be chosen to represent key stakeholders with an aim to include a wide range of institution types and geographical diversity. Lay representatives will include patients, relatives and charity works with experience in surgery worldwide.

What is a Delphi process?

A Delphi process is a proven method of developing consensus from a group of experts through iterative rounds of anonymous voting followed by group feedback. This technique gathers the opinions of experts within a field in order to assess the level of agreement and resolve disagreement on a specific topic, and is well suited to the global health agenda as it allows large numbers of geographically dispersed experts to contribute. All respondents will be listed as co-authors using a collaborative authorship model under the name of The Royal College of Surgeons of England Humanitarian Surgery Initiative.

This project seeks to gain consensus through a modified Delphi process over three rounds. A broad-based, international, multidisciplinary group of stakeholders will be identified to be as representative as possible and invited to take part via email. The stakeholders will be identified through a literature review, personal contacts of the authors and the RCS England’s Global Affairs department. Snowball sampling will be used through emails and social media channels to widen participation. The inclusion criteria are:

  • Age 18 or above
  • Ability to speak, read or write any of the six official languages of the United Nations: English, French, Spanish, Arabic, Russian, Chinese. Translation from English into other languages will be performed in conjunction with Translate Without Borders (TWB), a non-profit organisation offering translation services.

And at least one of the following is applicable:

  • Active in humanitarian or global surgery/ medicine/ research/ healthcare development or provision (within the last five years).
  • Currently (or within the last 12 months) affiliated with an organisation involved in global/ humanitarian surgery – these include – universities, professional societies, hospitals, other health care organisations, charities, and non-governmental organisations.
  • A representative from a patient or public group.
  • A healthcare worker (HCW) who works primarily in a Low/Middle Income Country (LMIC).

Delphi stages

A series of statements will be drawn up to cover the range of possible definitions by the Steering Group. These statements will be built into an online survey tool where respondents will be asked to rate their agreement with the statements on a Likert scale of 1 (strongly disagree) – 6 (strongly agree). An option to select ‘don’t know’ will be included as there will be a heterogenous group of respondents with varied experience. This survey will be piloted amongst a small group of academics, clinicians, and lay representatives prior to wider circulation. The three rounds will be conducted as follows:

1. Round one 
Idea generation stage. The members of the Humanitarian Surgery Initiative will be asked to answer the question: ‘What is Humanitarian Surgery?’. Free text answers to this question will be collated using an online survey tool and used, alongside a focused discussion by the Steering Group to formulate the statements for use in the Delphi process. Demographics will be collected as part of round one. The responses from round one will be collated and thematically analysed. Following this they will be used to build an online survey using Welphi.

2. Round two
The online survey will be sent to the stakeholders, each respondent will be asked to rate their agreement with the statements. As part of this round, respondents will be offered the opportunity to volunteer further ideas to be taken forward to future rounds. Demographic data will also be collected during this round. A two-week window will be given to complete the online survey and the results will then be analysed.

3. Round three 
An updated survey including the additional ideas generated from Delphi Round one will be sent to the respondents along with the individual’s previous responses and the group median response along with interquartile range (IQR) both in values and in graphical format.  Statements that reach agreement will be taken forward to the Definition Workshop. If an individual’s response lies outside of the IQR then they will be asked to give reasons for this in a free text answer.

4. Definition Workshop
On completion of the three Delphi rounds above, an online workshop will be held with the members of the RCS England HSI Steering Group to agree on the wording of the definition, including all the statements that reached consensus from the Delphi process.


On completion of the five stages, this project will have achieved an internationally agreed consensus on the term ‘humanitarian surgery’. This aims to stimulate debate on the topic and to focus further research on when ‘humanitarian surgery’, as defined, may be required, and what role it should play within the broader aims of improving surgical care across the world.

Sign up for updates

The results of the Delphi process are currently being analysed and the findings will be shared soon.  You can sign up for updates about this study.

funded and supported by Untied Kingdom Humanitarian Innovation Hub logo

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