Measuring health facility readiness for obstetric fistula surgery and care in Busoga sub-region, eastern Uganda: Development of scoring criteria/framework for facility readiness and application to six hospitals in the region
This study developed and applied a consensus-based seven-domain scoring framework to assess six hospitals in eastern Uganda, revealing that only one facility met the readiness threshold for routine obstetric fistula surgery due primarily to critical deficits in specialized human resources, equipment, and clinical protocols.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the eastern part of Uganda, a specific and devastating injury continues to affect thousands of women. Known as obstetric fistula, this condition occurs when a prolonged, obstructed labor goes untreated, causing a tear between the birth canal and the bladder or rectum. The result is a constant, uncontrollable leakage of urine or feces. Beyond the physical pain, this injury often leads to profound social isolation, as women are shunned by their communities due to the odor and the inability to control their bodies. While the injury can be repaired with surgery, the path to a cure is often blocked by a lack of access to skilled surgeons and the right equipment. In many low-resource settings, treatment is not a routine part of daily hospital care but is instead delivered through temporary, periodic camps. This approach leaves a massive backlog of women waiting for help, as the health system struggles to move from emergency, short-term fixes to a sustainable, integrated model of care.
To understand how to fix this system, researchers needed a way to measure exactly what a hospital needs to be ready to perform these complex repairs. In a new study focused on the Busoga sub-region of eastern Uganda, a team of experts set out to create a clear standard for what "readiness" looks like. They did not just guess; they brought together a panel of twenty-three specialists, including surgeons, policy makers, and academics, to agree on a specific checklist. This checklist was designed to weigh the importance of different factors, deciding that having a surgeon who lives and works at the hospital was far more critical than having a building with electricity. The team then applied this new scoring system to six hospitals in the region, ranging from large regional referral centers to smaller general hospitals, to see if they were truly prepared to treat women with fistula.
The researchers found that the gap between having a hospital building and having a hospital that can actually perform fistula surgery is wide. They developed a scoring framework that breaks down readiness into seven key areas: the people working there, the physical infrastructure, the medical equipment and supplies, supportive services like counseling, written rules for how to treat patients, systems for tracking results, and how the hospital is managed. The most heavily weighted part of this score was human resources, specifically the presence of a trained fistula surgeon who is permanently on staff, rather than one who visits occasionally. The team calculated a readiness score for each of the six hospitals, where a perfect score would mean the facility has everything it needs to provide high-quality, routine care.
The results revealed a stark reality. Only one of the six hospitals met the threshold to be considered ready for routine fistula surgery, achieving a score of 84 percent. This facility, a general hospital in a rural area, was the only one with a resident surgeon dedicated to fistula repair. Two other hospitals showed partial readiness, scoring between 65 and 69 percent, while the remaining three were classified as not ready, with scores as low as 38 percent. The primary reason for these low scores was not a lack of buildings or basic utilities like water and electricity, which were generally adequate. Instead, the failure lay in the specifics: most hospitals lacked the specialized surgical instrument sets required for this delicate work, did not have dedicated wards for fistula patients, and had no standardized protocols for how to manage the surgery or follow up with patients afterward.
A particularly telling finding was the difference between what hospitals claimed to have and what they actually had available for use. In one instance, a hospital reported that it had nearly 90 percent of the necessary supplies available, yet when the researchers checked how adequate those supplies were for performing a surgery, the score dropped to zero. This suggests that while items might be on a shelf, they are often the wrong type, insufficient in number, or of poor quality to sustain effective care. The study also highlighted that government-run hospitals were struggling the most, often lacking dedicated budgets for fistula care and relying on general funding that did not cover specialized needs. In contrast, the facilities that performed better were often supported by private, non-profit organizations and external partners who provided specific funding and resources.
The researchers concluded that the current model of relying on temporary camps and visiting surgeons is insufficient to clear the backlog of cases. The data shows that without a permanent, resident surgeon and a fully equipped, specialized team, a hospital cannot safely or effectively treat obstetric fistula on a routine basis. The study provides a practical tool for health officials to identify exactly where the gaps are, moving beyond vague ideas of "capacity" to specific, measurable deficits in staff, equipment, and management. By using this scoring system, policymakers can now see that the solution is not just to build more operating rooms, but to invest in the people and the specific tools that make those rooms functional. The path forward requires a shift from sporadic, campaign-style interventions to a decentralized system where every general hospital has the structural readiness to offer high-quality, continuous care.
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