Capacity building through workforce training and community engagement for Surgical, Obstetric, Trauma, and Anaesthesia (SOTA) care: Case studies from South Asia

South Asia faces a critical deficit in surgical, obstetric, trauma, and anaesthesia (SOTA) care, with over 1.6 billion people lacking access to safe and affordable surgical services. Addressing this inequity requires urgent workforce capacity building beyond traditional specialization. This study, conducted by the G4 Alliance Asia Working Group, employs a Multiple-Case Study design utilizing Cross-Case Synthesis to present six initiatives from Nepal, Bhutan, Pakistan, and India, mapped against a SOTA care workforce capacity building framework. We describe initiatives by training type (programmatic vs. non-programmatic), intent (upskilling vs. reskilling), and workforce outcomes such as task-shifting (delegating tasks to less specialized cadres), task-sharing (multi-cadre collaborative care), and task-creation (developing new cadre roles). Cross-case synthesis revealed distinct pathways for addressing workforce shortage and maldistribution. First, programmatic reskilling initiatives in Nepal, Bhutan, and Pakistan demonstrate how formalizing task shifting to mid-level providers and generalist doctors creates sustainable rural cadres recognized by national health systems. Second, non-programmatic models in India highlight the utility of upskilling existing surgeons to facilitate task sharing, thereby rapidly increasing the functional density of the workforce in resource-limited settings. Crucially, the analysis introduces task creation as a distinct workforce outcome to fill a specific "task-cadre gap" by establishing novel community engagement roles for SOTA care that do not exist in standard hierarchies. The synthesis indicates that while programmatic models support long-term retention through state absorption, non-programmatic interventions offer vital flexibility for immediate service delivery. Indigenously initiated, state-integrated models, providing secure career paths, achieved better sustainability, whereas foreign donor-dependent and non-programmatic models faced challenges. These initiatives underscore that locally driven, context-specific solutions can effectively bridge healthcare disparities. Facilitating cross-learning on the successes and limitations of these diverse models is essential to scale effective interventions and integrate them into national and regional policy plans, thereby ensuring equitable access to SOTA care across South Asia.