Sierra Leone’s maternal mortality rate was once among the highest in the world. A 15-year nonprofit program that trains community health workers to perform life-saving surgeries has helped cut that risk by two-thirds.
Fourteen years ago, Haakon Volkan, a surgeon at the Norwegian University of Science and Technology (NTNU), predicted a new training program he and his colleagues were starting to expand access to surgery in the West African country of Sierra Leone.
I believe that if this program continues for several years,[its graduates]will become the core of surgical care in regional hospitals in Sierra Leone. ”
Haakon Volkan, NTNU Surgeon
As it turns out, he was right.
The impact of the CapaCare trainees was “transformational.”
CapaCare, the nonprofit organization he founded, is currently training 113 community health workers to provide life-saving surgeries such as emergency C-sections. A recent academic publication explains exactly what this means.
“Currently, almost 8,000 of the 14,000 C-sections are performed by the groups we have trained,” Volcan said. “This represents almost 60 percent of all C-sections performed in the country.”
More importantly, “Sierra Leone has seen its maternal mortality rate fall by almost a third, one of the sharpest declines in Africa over the past decade,” Volkan said.
One of the factors behind this drastic decrease is that emergency obstetric care is now available at all hospitals throughout the country, day and night. Virtually all Caesarean sections in Sierra Leone are emergency surgeries. Being able to provide them has saved many women’s lives.
This approach has been so successful that CapaCare has expanded its activities to Liberia starting in 2021.
So what is magic?
Huge unmet needs
First of all, it is important to understand how difficult it is for people in low- and middle-income countries to access the surgical treatment they need.
A landmark assessment by the Lancet Commission in 2015 estimated that approximately 5 billion people worldwide lack access to safe surgical treatment. The 2025 update shows that the need has only grown in the decade since the first assessment was published.
The reasons for this gap in care are many.
Sierra Leone and Liberia simply don’t have enough doctors, and even fewer trained surgeons.
For example, long-running civil wars in both Sierra Leone and Liberia have destroyed hospitals and other infrastructure, making it difficult to provide health care to their populations.
In 2014, both countries were hit by the West African Ebola outbreak, the largest in history.
Perhaps the biggest factor is that there simply aren’t enough doctors in both regions, and even fewer trained surgeons.
In Sierra Leone, for example, only 10 surgeons worked in hospitals surveyed by CapaCare in 2012. This is the number of specialists for every 700,000 people. By contrast, Norway has 67 specialist surgeons for every 100,000 people, according to the World Bank.
Adopt task sharing and prove it works
A solution to this problem, called task sharing, was already being tried in East Africa in the 1960s.
In 2007, the World Health Organization formally endorsed this approach as a way to address access to HIV antiretroviral treatment in Africa.
Task sharing involves training health workers to provide services typically provided by physicians, including life-saving surgeries such as appendectomies, hernia repairs, and caesarean sections.
That’s the approach Volkan and his colleagues decided to take. The plan is to accept candidates from Sierra Leone’s Community Health Officer Program and give them two years of training to perform the surgery. After training, they were called SACHOs (Surgical Assistant Community Health Officers).
Is the surgical treatment provided by SACHO as good as that provided by trained surgeons? Was it safe? A series of research papers over the past decade answer that question with a resounding “yes.”
That was the first part of the special sauce that led to CapaCare’s success.
The second became Volkan’s PhD project at NTNU. His paper documented the need for surgery in this country and established standards for the type of care provided (or more accurately, not).
But what Volkan and Capacare really needed to address was, ultimately, the question: Is the surgical care provided by SACHO as good as that provided by trained surgeons? Was it safe?
A series of research papers over the past decade answer that question with a resounding “yes.”
government approval
Providing assurance that task sharing was safe and that there were unmet needs gave Sierra Leone’s Ministry of Health confidence that the program would work for the country.
This, coupled with the country’s efforts to train more midwives and increase ambulance services, was essential to reducing maternal mortality rates.
Now, one CapaCare graduate has contributed to the creation of the updated Republic of Sierra Leone National Surgical, Obstetric, and Anesthesiology Plan, which explicitly supports task-shared training.
The plan describes the impact of CapaCare trainees as “transformational.”
“By 2023, these non-physician clinicians will perform 41% of all surgical procedures nationwide. (57.6% nationwide), contributing to improved access to emergency obstetric care.The total number of surgical providers (all executives) more than doubled from 2012 to 2023 (165 people). 347 from 2012 to 2023),” the report states.
While this is progress, it is still not enough, the report says.
take a different path
As the Sierra Leone project matured, it seemed natural to reach out to neighboring Liberia, which also has a shortage of health care providers.
The first step was to categorize the types of services available and unmet needs, the results of which were published in 2020. The study estimated the “surgery volume” in 2018 to be 462 surgeries per 100,000 people.
For comparison, Sierra Leone’s national surgical volume increased from 400 to 505 per 100,000 population between 2012 and 2023.
Around the world, the Lancet Global Surgical Commission has proposed standards that would allow countries to provide 5,000 surgical procedures per 100,000 people.
“When we started our journey in Liberia, we wanted to copy some of our experience in Sierra Leone to Liberia and have more task sharing,” said Alex van Duinen, who has worked extensively in both Sierra Leone and Liberia with CapaCare and is also a postdoctoral researcher at NTNU.
Liberia turned out to be much more interested in having more specialized training for surgeons and obstetricians. That’s why CapaCare is now supporting specialist training there, Van Duinen said.
It also helped Volkan and Van Duinen recognize the need to expand specialist training in Sierra Leone.
“It was actually a surprising turn of events,” Van Duinen said.
In Sierra Leone, “we need to make sure the system is balanced and we can’t just lift up the lowest-level surgical providers,” Van Duinen said.
Currently, CapaCare supports courses and training for doctors and specialists in Sierra Leone, as well as training for community health personnel.
“We are also working with the Ministry of Health and the College of Surgeons of Sierra Leone to raise funds to strengthen residency training, as funding is too low,” Bolkan said. “For a population of 8 million people, there are only six or seven surgical trainees at any given time.”
Challenges remain, but trends are bright
One of the unresolved challenges facing CapaCare is that approximately half of the community health workers it originally trained still lack legal recognition and protection.
The group has indeed gained that recognition after being trained through the training programs developed by CapaCare and the Ministry of Health.
“This creates challenges in terms of career development and recognition,” Van Duinen said.
In at least one case, one of CapaCare’s early trainees was sufficiently frustrated by the lack of recognition that he decided to attend medical school, Volcan said.
“So I met him in January of this year and congratulated him and asked him, ‘Do you regret starting our training? Would you have done things differently?'” And he was very clear. He said, “No, I don’t regret anything.” Thanks to your training, you built trust in me and believed that I believed in myself,” Volkan said.
Despite these challenges, Volkan is optimistic that Sierra Leone, for example, can achieve important milestones in the coming years.
“The (United Nations) Sustainable Development Goals specify that a country’s maternal mortality rate should be 70 deaths per 100,000 people,” Volcan said.
He said that when CapaCare began, the country’s maternal mortality rate was more than 1,000 deaths per 100,000 people.
“In 2024, it was around 300 people. If Sierra Leone continues to make progress, I wouldn’t be surprised if by 2030 it would be below 70 people, and no one thought it was possible to get that close,” he said.
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Norwegian University of Science and Technology (NTNU)
