 This study examined the challenges of scaling up surgery at district hospitals in Tanzania. The study used a participatory research approach involving a group model building session and inductive thematic analysis to identify the key factors affecting surgical scale-up. The findings revealed five themes, patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. Additionally, six self-reinforcing feedback loops and four self-correcting feedback loops were identified. The study concluded that policy makers should be cautious when implementing quick fixes as they may not provide long-term solutions. Instead, policies should consider the complex dynamics of surgical systems and allow for periodic evaluation and adaptation to ensure sustained surgical scale-up. This article was authored by Hank Brokwazin, Monik Lansu, Jakub Kajewski, and others. We are article.tv, links in the description below.