Africa faces a critical shortage of surgical workforce, projected to reach six million providers by 2030. With a surgeon-to-population ratio of about 0.5 per 100,000, the lowest globally, the continent continues to experience major unmet surgical needs and preventable deaths. Rwanda follows the same trends. Surgical education in Rwanda, however, is undergoing a government-led transformation. A once centralized and limited system is evolving into a decentralized, high-output, context-specific model aimed at making safe surgery accessible nationwide. The reform prioritizes workforce expansion, simulation-based training, and strong academic partnerships. Rapid expansion through the “4x4” Program Rwanda currently has 172 surgeons, far below the estimated need of 1,400. The national “4x4” Program aims to quadruple the number of healthcare specialists, including surgeons, within four years. Previously, Rwanda graduated about 10 surgeons annually. Recently, more than 60 first-year residents were enrolled in a single year, bringing the total surgical trainees to 226. While this growth is encouraging, expansion must be matched with strict quality assurance. Increasing numbers alone is insufficient; surgeons must be competent and safe practitioners. Decentralization is another key reform. Training is expanding beyond Kigali into district hospitals, allowing trainees to learn in real-world settings while serving communities. This promotes equity, lowers patient costs, and embeds surgical education within community healthcare systems. Context-specific training and innovation Rwanda has moved from importing foreign curricula to developing programmes tailored to local needs. All trainees begin with a foundation focused on Rwanda’s disease burden, particularly “bellwether” procedures such as laparotomy, cesarean section, and open fracture management. This is followed by 4–6 years of specialty training in General Surgery, Neurosurgery, Orthopedics, Urology, Plastic Surgery, ENT, Pediatric Surgery, Maxillofacial Surgery, and Ophthalmology. Additional 2–3 year fellowships are available in Cardiothoracic Surgery, Breast Surgery, Colorectal Surgery, Minimally Invasive Surgery, Kidney Transplantation, Otology, Trauma, and Surgical Critical Care. Training emphasizes adaptability in low-resource settings, encouraging safe innovation and optimal use of available resources. Research is integrated; all residents must complete and defend a dissertation, reinforcing evidence-based practice. The Global Surgery Research Hub at the University of Rwanda supports national collaboration and impactful research to improve surgical outcomes locally and internationally. Educational models and partnerships Surgical education is strengthened by national and international collaborations focused on mentorship and hands-on learning. The University of Rwanda, College of Medicine and Health Sciences, runs hospital-based modular residencies in partnership with four university teaching hospitals and ten Level 2 teaching hospitals, promoting distributed training. Africa Health Sciences University (AHSU), in partnership with King Faisal Hospital, has launched residency programs and hosts fellowship programs in collaboration with the University of Rwanda. The University of Global Health Equity (UGHE) has introduced a General Surgery residency aligned with COSECSA standards, emphasizing leadership and social accountability. Simulation-based training is central to surgical education, allowing trainees to refine technical skills in controlled environments. Technologies such as Proximie are being explored to enhance supervision and reduce operating room overcrowding. However, simulation cannot replace operative exposure; expanding surgical volume and theater capacity remains essential. International partnerships, including collaborations with Operation Smile and the American College of Surgeons, contribute visiting professors and subspecialty expertise in areas such as Plastic Surgery, Vascular Surgery, and Kidney Transplantation. These partnerships build local faculty capacity while maintaining standards. Challenges and way forward Despite progress, challenges remain. Rwanda has approximately 0.9 operating theaters per 100,000 population, far below the recommended 5–6. Limited theater space, equipment shortages, and high workloads restrict trainee exposure and supervision. Sustaining mentorship in highly specialized fields is also difficult. Clearer governance structures and defined career pathways are needed to develop academic leaders. Future priorities include strengthening non-technical skills such as teamwork and decision-making, and better integrating Community Health Workers into perioperative care to improve follow-up and reduce complications. The long-term vision of “a surgeon in every district” aims to anchor both surgical care and education within rural health systems, with Level 2 teaching hospitals serving as primary training sites. Rwandan surgical education remains a work in progress, driven by political commitment, strategic partnerships, and context-aware innovation. Despite infrastructure and system challenges, Rwanda is steadily building a decentralized, academically grounded, and socially accountable surgical workforce capable of meeting present and future needs. Dr. Faustin Ntirenganya is a professor of plastic and reconstructive surgery, Chair of the Department of Surgery at the School of Medicine and Pharmacy, College of Medicine and Health Sciences, and Director of Global Surgery Research Hub of University of Rwanda.
