Abstract
Surgical safety remains a critical yet often overlooked priority in low-resource countries, particularly in post-armed
conflict settings like Somalia. Decades of instability have left the Somali healthcare system fragmented and severely under-resourced, contributing to a high burden of avoidable surgical complications and perioperativemortality. In response to these challenges, the World Health Organization (WHO) developed the Surgical Safety Checklist (SSC), a globally recognized tool designed to reduce surgical harm, enhance communication,and foster teamwork in operating theatres. Although widely adopted in many health systems, evidence on its implementation and effectiveness in Somalia has been notably absent. The country’s unique constraints,
including inadequate infrastructure, variable clinical training, and fluid surgical team structures, raise important
considerations about the adaptability and sustainability of global safety initiatives in such environments. To address
this gap, we implemented the WHO SSC in 15 hospitals across Mogadishu, aiming to evaluate its feasibility,
measure improvements in adherence, and examine its influence on promoting a culture of surgical safety within
resource-limited settings. Beyond improving procedural compliance, the intervention sought to determine
whether structured training and frontline engagement could mitigate systemic barriers to safe surgical care. This
study contributes valuable insights for global health stakeholders and policy-makers seeking to contextualize
and scale evidence-based safety practices in settings characterized by conflict, institutional fragility, or chronic
underinvestment in health systems.

Keywords WHO surgical safety checklist, Patient morbidity, Safe surgery saves lives, Resource-constrained settings