Somali health workers know WHO surgical safety checklist, adoption remains low

Analysis: In Mogadishu’s Operating Rooms, a Simple Checklist Meets a Tough Reality

In a city where surgeons work under the hum of generators and the steady pressure of backlogged cases, a new study from Mogadishu has surfaced a paradox at the heart of patient safety: most clinicians know the World Health Organization’s surgical safety checklist, but relatively few use it. In Somalia’s fragile health system, that gap between knowledge and practice can be the difference between a safe outcome and a preventable tragedy.

What the study found

Researchers at SIMAD University surveyed 422 clinicians in Mogadishu—doctors, nurses, and anesthesiology staff—between April and July 2024. The results are jarring: while 81% of respondents demonstrated strong familiarity with the WHO’s 19-step surgical safety checklist, just 13.5% reported a positive attitude toward using it regularly during operations. Nearly 88% acknowledged that the checklist improves patient safety, yet many worried it would slow down procedures or delay the day’s tightly packed schedule.

The study—authored by Najib Isse Dirie, Abdullahi Hassan Elmi, Mohamed Mustaf Ahmed, Abdishakor Mohamud Ahmed, Omar Mohamed Olad, and Mulki Mukhtar Hassan—doesn’t claim that Mogadishu is unique. Rather, it reveals a pattern seen across low-resource health systems: when time, staff, and equipment are scarce, protocols that require teamwork and deliberate pauses can feel like a luxury. But the authors argue they are precisely the opposite—a low-cost intervention that saves lives when everything else is stretched.

Why the gap matters

Since its launch in 2008 under the banner “Safe Surgery Saves Lives,” the WHO checklist has been one of the clearest, most evidence-based tools in modern patient safety. A landmark study led by researcher and surgeon Atul Gawande found that implementing the checklist across eight diverse hospitals reduced major complications by roughly a third and deaths by nearly half. Globally, it’s been credited with standardizing communications in the operating room, helping teams verify the basics—patient identity, procedure, antibiotic prophylaxis, airway plan—before the first incision.

Somalia has little margin for error. Decades of conflict hollowed out institutions and diverted resources to urgent crises: cholera outbreaks, drought, mass displacement. Surgical care was never absent, but it wasn’t the centerpiece of international health funding either. The operating room usually doesn’t make headlines. Yet the Lancet Commission on Global Surgery estimates that five billion people worldwide lack access to safe, affordable surgical and anesthesia care, and that up to 143 million additional procedures are needed annually to save lives and prevent disability. In this context, a near-costless checklist is not a bureaucratic hurdle; it’s a basic safety net.

Lessons from neighbors

The SIMAD team situates Somalia’s findings within a broader East African arc. Ethiopia saw strong early adoption of the checklist, then a tapering off when supervision and refresher training waned. Tanzania, by contrast, sustained progress through continuous mentorship and adaptation to local realities—training sessions embedded within hospitals, champions appointed inside ORs, and periodic data feedback to staff. The difference wasn’t in the tool; it was in the follow-through.

In Mogadishu’s survey, most respondents were under 30, with fewer than five years of experience—an asset if harnessed, a vulnerability if not. Younger staff are often more open to new practices and digital tools, but they need role models to show how the checklist strengthens—not weakens—clinical judgment. This is a leadership story as much as a technical one.

The culture of the OR

Every operating room has its rhythms and hierarchies. In many settings, surgeons carry the cultural weight of authority; if they embrace the checklist, others follow. If they don’t, even the best-intentioned nurse can struggle to insist on that “time out” before an incision.

There is also the time pressure. Ask anyone who’s worked a surgical list in a low-resource setting and they’ll tell you: electricity is sporadic, essential lab results may be delayed, a single oxygen cylinder might serve more than one room. The day feels like it could slip at any moment—so shaving off a minute or two can feel like survival. But the evidence is plain: the “minute” sacrificed to the checklist pays itself back with fewer complications and smoother teamwork. Groups like Lifebox—founded to improve surgical safety in low-income settings—have shown that pairing checklists with basic tools such as pulse oximetry and targeted training can build habits that last beyond initial enthusiasm.

What could work in Somalia

The SIMAD authors don’t stop at diagnosis; they prescribe a treatment plan. First, tailor training to roles: a scrub nurse’s responsibilities on the checklist differ from those of an anesthetist or a surgeon. Teach to those differences, and practice them in scenario-based simulations. Second, cultivate champions—respected clinicians who run the checklist as a non-negotiable step, not an optional add-on. Third, enlist hospital leadership. When administrators carve out ten extra minutes for each case and protect that time, the clinical culture shifts. Without that support, checklists get pushed to the margins.

The study also urges a 21st-century update: bring in digital tools that make the checklist practical. In some hospitals, a tablet or wall-mounted display with a Somali-language interface could walk teams through the steps, capture compliance data, and provide feedback. Even a simple phone-based app—localized and offline-capable—could reduce the perception that the checklist is a “paper exercise.” And in a city where many caregivers are digital natives, that matters.

The global picture—and a fair question

There’s a tendency to assume that patient safety is a luxury for well-funded systems. The opposite is true. When supplies are short and workloads heavy, the margin for error shrinks, and small safeguards carry outsized impact. The WHO checklist is not a cure-all; it won’t fix broken autoclaves or staff shortages. But it is a bulwark against the most human of vulnerabilities: the mistakes we make when we are rushed, tired, or unsure.

So the question for Somalia is not whether clinicians know the checklist—they do. The question is whether the system will make it feasible, expected, and proud to use it. That will require leadership from health ministries and hospital directors, support from donors who traditionally fund infectious disease but hesitate at surgical budgets, and humility from all of us who have worked in operating rooms: to pause, speak up, and listen.

A decade and a half after the WHO launched its campaign, the slogan still rings true. Safe surgery does save lives. In Mogadishu, it could save them by the dozens each week—if a tool already at hand is given the chance to work.

By Ali Musa
Axadle Times international–Monitoring.