Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda

Abstract

Introduction/Background:

Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda.

Methods:

We administered the Children’s Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains.

Results:

None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance).

Conclusions:

This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.

Introduction:

Safe, quality surgery is an essential component of child health.¹ While morbidity and mortality from infectious diseases and perinatal complications has declined, the burden of congenital, noncommunicable and surgical diseases has increased dramatically.² This shift is particularly pronounced in low- and middle-income countries (LMICs), with reports of up to 85% of children having surgically treatable conditions by age 15, compared to 11% of adults.^2,3 This increase in burden is compounded by limited access to surgical services, with the poorest 30% of the global population reporting only 3-6% of all surgical interventions.⁴ Moreover, children undergoing surgery in LMICs face higher mortality rates, underscoring the urgent need for quality surgical care in these settings.^4,5

In East Africa, estimates for the prevalence of untreated surgical conditions range from 7.4% - 39%, and individuals aged < 21 years reported as being twice as likely to have an untreated surgical condition.^6–10 Thirty percent of surgical patients with non-obstetric conditions are children.¹¹ Injuries from burns, falls, and motor vehicle accidents are leading causes of mortality among children and commonly require surgery and transfer to a higher level of care.¹² Yet, children with traumatic injuries in rural Rwanda are much more likely to experience delay in referrals compared to adults.¹³

While there has been increased support to improve surgical access in LMICs, this support is variable across care levels and settings, even among those implementing the same intervention.¹⁴ One determinant is the pre-implementation readiness of surgical facilities, both in terms of organizational characteristics as well as facility infrastructure.¹⁵ The concept of organizational readiness for change has become increasingly important in implementation science. While readiness encompasses a variety of complex social, psychological, and contextual components, more simply, readiness refers to a state of being prepared for future actions.^15,16 While the issue of readiness is not exclusive to LMICs, assessing these characteristics can provide setting-specific evidence for scaling quality improvement interventions in LMICs. The Safe Surgery Organizational Readiness Tool (SSORT) was developed to evaluate surgical facility members’ baseline beliefs and attitudes toward quality improvement and safety interventions in surgical care.¹⁵ The goal of this assessment is to identify potential barriers to implementation such that interventions can be better tailored to promote success.

In addition to organizational readiness, infrastructure capacity is also a key determinant of the ability to provide high quality surgical care to children. There are large human and material resource gaps to providing pediatric surgical care in Africa.¹⁷ Yet only 7% of national health policies, strategies, and plans mention pediatric surgery.¹⁸ Prior evaluations assessing the capacity for safe surgical and anesthesia care in Rwanda have utilized assessments such as the Program in Global Surgery and Social Change/World Health Organization Surgical Assessment Tool (SAT).¹⁹ While some pediatric conditions are included on this evaluation, they are reported as a subset of adult diseases and pediatric specific equipment, infrastructure, and workforce gaps are not specifically addressed. The Global Initiative for Children’s Surgery (GICS) developed a pediatric adaptation of this tool for Nigeria, which was adapted for use in Rwandan district hospitals.

To inform policies and programs to improve surgical access and outcomes for pediatric patients at the district hospital level in Rwanda and the region, this study aimed to assess facility-level infrastructure and readiness to expand surgical services at three facilities in rural Rwanda.

Methods:

Study Setting and Population:

The healthcare system in Rwanda is divided into four tiers: community health workers who provide basic healthcare services and education in communities, health centers which provide primary care, district hospitals that provide more specialized care including surgical care, and referral hospitals which offer the highest level of specialized care. There are 36 district hospitals and four provincial hospitals in Rwanda with variable ability to provide surgical care. There are eight national referral hospitals, including four in the capital capital, Kigali.

The study was conducted at three of the 36 Ministry of Health-run district hospitals in rural Rwanda. These hospitals, Rwinkwavu District Hospital (RDH) and Kirehe District Hospital (KDH) in the Eastern Province, and Butaro District Hospital (BDH) in the Northern Province, receive financial and medical support from Partners In Health/ Inshuti Mu Buzima (PIH/IMB), an international US-based non-governmental organization (NGO). The catchment populations are approximately 292,000 for RDH and 265,000 for KDH and 340,000 for BDH. KDH and RDH have no surgeons and BDH has two general surgeons on staff. While all three sites can perform some minor procedures on children, Butaro District Hospital is the only site that has performed any pediatric operations. Children requiring general anesthesia are referred to tertiary national referral hospitals.²⁰ In Rwanda, there are three fellowship-trained pediatric surgeons, leading to surgical volume backlog and treatment delay for many pediatric patients. In 2017, Rwanda developed a National Surgical Obstetric and Anesthesia Plan (NSOAP) with an emphasis on increasing access to surgical care, particularly at the district hospital level.²¹ While pediatric surgery is acknowledged as necessity, there is no specific plan for implementation of interventions to increase access to pediatric surgical care at the district hospital level.

Survey Tools:

This cross-sectional study used two tools - a Rwandan district hospital adaptation of the Children’s Surgical Assessment Tool (CSAT_R) and the Safe Surgery Organizational Readiness Tool (SSORT). The CSAT_R is a comprehensive list of components necessary to deliver surgical care for pediatric patients.²² This tool was developed based on aggregated available guidelines to systematically assess surgical systems and help monitor, modify, and strengthen them in a scalable fashion. The CSAT aims to identify gaps in facility infrastructure, service delivery, workforce, information management, and financing.²² Our team adapted and validated this tool for a Rwandan district-hospital level assessment, as described elsewhere.²³The SSORT assesses facility members’ attitudes and beliefs regarding 14 domains at the individual, team, and organizational levels, providing insight into the readiness of surgical facilities in LMICs to implement surgical safety and quality improvement interventions.¹⁵ The SSORT survey underwent a cross-cultural adaption process as described by Beaton et al., 2000.²⁴

Data collection:

CSAT:

The CSAT_R was administered by trained data collectors. Assessment consisted of semi-structured interviews supplemented or verified with a hospital walkthrough, review of logbooks, and via Health Information Management Systems reports. The study team used a CSAT_R administration guide to ensure standardization of data collection and provide recommendations for data sources for each section of the tool (Appendix 1).

SSORT:

The SSORT was administered to 10-15 participants from each district hospital. The participants included general practitioners, surgeons, nurses, anesthesiologists, and hospital leadership that were identified via purposive sampling through recommendations by the hospital leadership of those most appropriate to the focus of the study. Participants were offered the option of completing the survey in English or Kinyarwanda. Participants were asked to rank 56 items across 14 domains on a 5-point Likert scale (1= strongly disagree, 5 = strongly agree).

Data Analysis and Statistical Methods:

Descriptive statistics (mean, median, interquartile range, standard deviation) were calculated for variables data collected. For the SSORT, descriptive statistics were calculated for both individual questions and by domain. Three questions with negative phrasing (opposite the Likert scale from the remaining questions) were reverse coded prior to analysis. Analysis was performed using STATA v15.0 (StataCorp, College Station, TX).

Results:

CSAT_R Results:

Facility information:

A total of 11, 12 and 9 personnel were interviewed at BDH, KDH and RDH, respectively. Across the three sites, there were 3,437 inpatient admissions, 176 emergency department visits, and 3,384 outpatient visits for children under 5 years old in the year 2022. There were 163 surgical admissions and 68 surgical outpatient visits for children under 5 years old. For children 5-15 years old, there were 1,226 inpatient admissions, 166 emergency department visits, and 4,270 outpatient visits. There were 163 surgical admissions and 195 surgical outpatient visits for children 5-15 years old. The full results by hospital site are detailed in Table 1.

Table 1.

a. CSAT Results – FACILITY INFORMATION

Item	Butaro	Kirehe	Rwinkwavu
For children <5 years old:
Total number of pediatric inpatient admissions (>6 hours in non-emergency ward) for children <5 in a year	1379	802	1256
Total number of pediatric Emergency Department visits for children <5 in a year	92	14	70
Total number of pediatric outpatient visits for children <5 in a year	1493	208	1683
Total number of children’s surgical admissions for children <5 in a year	46	58	59
Total number of children’s surgical outpatients (visits) for children < 5 seen in a year	36	21	11
For children 5-15 years old:
Total number of pediatric inpatient admissions (>6 hours in non-emergency ward) for children 5-15 years-old in a year	1041	113	72
Total number of pediatric Emergency Department visits for children 5-15 years-old in a year	105	19	42
Total number of pediatric outpatient visits for children 5-15 years-old in a year	2071	303	1896
Total number of children’s surgical admissions for children 5-15 years-old in a year	31	106	26
Total number of children’s surgical outpatients (visits) for children 5-15 years-old seen in a year	51	68	76
Facility Information:
Total number of inpatient hospital beds dedicated to children’s surgery	0*	0	0
Does your hospital have a pediatric recovery room?	No*	No	No
Total number of recovery room hospital beds dedicated to children’s surgery	2	0	0
Is oxygen available in the recovery room?	N/A*	N/A	N/A
Total number of operating rooms in the hospital	2	2	1
Total number children’s operating rooms	0	0	0
Total number of neonatal unit/special baby care unit beds	19	37	22
Does your hospital have a post-operative ICU?	No	NICU only	Yes**
Total number of pediatric ICU/advanced care beds	N/A	0	2
Total number of neonatal ICU beds	N/A	4	8
Total number of functional pediatric ventilators in the ICU	NA	0	0
Total number of functional neonatal ventilators in ICU	NA	0	4
Total number of functional incubators or pediatric warmers	5 (neonatal)	11	6
Total number of patient monitors in pediatric and neonatal ICU	0	10	5
How many of these monitors include all of the following: EKG, blood pressure, pulse oximetry, temperature and capnography?	0	0	3
Access and referral systems:
How many patients <5 years old per year do you refer to higher-level facilities for surgical interventions?	25	6	7
How many patients 5-15 years old per year do you refer to higher-level facilities for surgical interventions?	26	19	13
What is the most common reason for referral of pediatric surgical patients < 5 years old to higher levels of care?	Undescended testicle	Orthopedic cases	Abscess
What is the most common reason for referral of pediatric surgical patients 5-15 years old to higher levels of care?	Osteomyelitis	Fractures requiring scanner	Fracture requiring scanner
How far away is the nearest referral hospital (minutes, by car)	120	120	40
General Infrastructure - How often is this item available and functional? Unavailable (0), Inadequate (1) Limited (2) Adequate (3)
24-hour Emergency Unit able to receive pediatric patients	3	3	3
Pharmacy – product availability
Pediatric malnutrition feeding program	3	3	3
Pediatric dosing cognitive aid or guide	3	3	3
Radiology & Pathology – service availability
Enteral contrast material for bowel evaluation (barium or gastrografin)	0	0	0
Intravenous contrast material	0	0	0
Echocardiogram	0	3	3
Ultrasound	2	3	3
X-ray	3	3	3
Anatomic Pathology services	3	0	0
Blood Supply - availability
Blood component transfusion	3	3	3
Service Delivery (n=47)
Number of procedures able to perform	27 (57.4%)	8 (17.0%)	11 (23.4%)
Number adequate	8 (17.0%)	3 (6.4%)	2 (4.3%)
Number Limited or inadequate	19 (40.4%)	4 (8.5%)	9 (19.1%)
Unavailable	19 (40.4%)	38 (80.9%)	36 (76.6%)
Total performed	38	250	54
Service Delivery (n=47 procedures)
Infrastructure	14 (29.8%)	4 (8.5%)	7 (14.9%)
Absent	10 (21.3%)	31 (66.0%)	36 (76.6%)
Broken	3 (11.1%)	1 (2.1%)	2 (4.3%)
Personnel	20 (42.6%)	25 (53.2%)	7(14.9%)
Training	20 (42.6%)	38(80.9%)	33 (70.2%)
Stock Out	7 (14.9%)	0 (0%)	5 (10.6%)
User Fees	0 (0%)	0 (0%)	0 (0%)
Other	22 (46.8%)	30 (63.8%)	38 (80.9%)
Other Barriers: Lack of Anesthesiologist	16 (34.0%)	4 (8.5%)	7 (14.9%)
Other Barriers: Lack of specialists	2 (4.3%)	4 (8.5%)	9 (19.1%)
Other Barriers: Lack of imaging/pathology services	1 (2.1%)	19 (40.4%)	0 (0%)
Other Barriers: Other not specified	5 (10.6%)	8 (17.0%)	6 (12.8%)
Operating Equipment and Supplies (n=18 equipment)
Number adequate	9 (50%)	0 (0%)	4 (22.2%)
Number Limited or inadequate	1 (5.6%)	10 (55.6%)	0 (0%)
Unavailable	8 (44.4%)	8 (44.4%)	14 (77.8%)
Operating Equipment and Supplies (n=18 equipment)
Infrastructure	2 (11.1%)	2 (11.1%)	0 (0%)
Absent	1 (5.56%)	7 (38.9%)	14 (77.8%)
Broken	1 (5.56%)	0 (0%)	0 (0%)
Personnel	2 (11.1%)	2 (11.1%)	0 (0%)
Training	2 (11.1%)	0 (0%)	0 (0%)
Stock Out	1 (5.56%)	0 (0%)	0 (0%)
User Fees	0 (0%)	0 (0%)	0 (0%)
Other	4 (22.2%)	4 (22.2%)	0 (0%)
Quality and Safety
Is your institution involved in a formal training program for surgical trainees?	No	No	No
Does your institution use electronic medical records?	Yes	Yes	Yes
Does your institution have a method of monitoring surgical outcomes over time?	Yes	Yes	No
Does your institution have a trauma registry that includes pediatric trauma?	Yes	Yes	No
Number of post-operative pediatric (<5 y/o) in-hospital deaths last year	0	0	N/A
Number of post-operative pediatric (5-15 y/o) in-hospital deaths last year	0	0	N/A
Number of surgical site infections(SSIs) in pediatric patients (< 15 y/o) in the last year	0	0	N/A
What is the highest ASA class of children operated at your institution? (ASA I = healthy patient, ASA II = patient with mild systemic disease, ASA III = patient with severe systemic disease, ASA IV = patient with severe systemic disease that is a constant threat to life)	ASA II	ASA I	N/A
Is the WHO Surgical Safety Checklist used in the operating rooms for pediatric patients?	All the time	N/A	N/A
Is pulse oximetry used in the operating rooms for pediatric patients?	All the time	N/A	N/A
How often does the hospital hold a surgical audit (Mortality and Morbidity conference) related to children’s surgical patients?	Never	Never	Never
Number of qualified general surgeons with pediatric exposure (trained surgeons with expertise in pediatric or neonatal surgery, but without formal subspecialty pediatric surgical training)	2	0	0
Number of qualified general pediatric surgeons (trained surgeons with formal specialized training in children’s surgery of≥ 1 year)	0	0	0
Number of general doctors providing pediatric surgery (general practitioners without formal surgical training)	0	0	0
Number of non-physicians providing pediatric procedure (non-physicians health care professional who performs procedures independently without formal training in surgery). These procedures include circumcision, reduction of closed fractures, small wound repair, debridement, minor skin grafts.	3	15	5
Number of qualified anesthesiologists	0	0	0
Number of qualified pediatric anesthesiologists (trained anesthesiologists with formal specialization)	0	0	0
Number of general doctors providing pediatric anesthesia (general practitioners without formal anesthesiology training)	0	0	0
Number of non-physicians providing pediatric anesthesia (non-physicians health care professionals who perform pediatric anesthesia independently without formal training in anesthesia)	5 full time	3 full time + 4 part time	5 full time
Number of nurses with training or exposure in pediatric surgery, who treat only children	0	0	0
Number of visiting or consultant physicians who are involved in pediatric surgical care (visiting at least 1x/week for at least 1 year).	0	0	0
Pediatric Specialists
General pediatrician	2	2	1
Cardiac Surgeon	0	0	0
Dental Surgeon	0	1	0
Neurosurgeon	0	0	0
Ophthalmologist	0	0	0
Orthopedic surgeon	0	0	0
Otorhinolaryngologist (ENT)	0	0	0
Plastic surgeon	0	0	0
Urologist	0	0	0
Hematologist	0	0	0
Nephrologist	0	0	0
Neurologist	0	0	0
Respiratory physician	0	0	0
Neonatologist	0	0	0
Cardiologist	0	0	0
Endocrinologist	0	0	0
Physiotherapist	0	1	0
Pediatric intensive care nurse	0	0	0
Neonatal nurse	0	1	0
Qualified nutritionist	2	1	1
Radiographer	0	0	2
Radiologist	0	1	0
Speech therapist	0	0	0
Audiologist	0	0	0
Pathologist	3	0	0
Oncologist treating children	0	0	0
Ophthalmology technician	1	1	1
Work Force Availability (How often are these available 24 hours a day?) Unavailable (0), Inadequate (1) Limited (2) Adequate (3)
General surgeon or pediatric surgeon availability	2	0	0
Pediatric anesthesia provider availability (with >6 months of training or exposure in pediatrics)	0	0	0
Health financing and accounting
What percentage of children coming to this hospital have health insurance	More than half	More than half	More than half
Nationally, is there government-sponsored health insurance/financing for children?	Yes	Yes	Yes
On average, what percentage pediatric surgical costs for patients are covered by insurance?	99.00%	99.00%	N/A
Budget Allocation
Annual hospital budget allotted to children’s surgery and anesthesia
Actual amount:	N/A	N/A	N/A
% of total budget:	N/A	N/A	N/A
Average total inpatient cost for:
Pediatric hernia/hydrocele repair	$26, 910	$7,800	N/A
Pediatric fracture management	$9,315	$1,050	N/A
Pediatric laparotomy	$24,800	$6,080	N/A
Pediatric appendectomy	$31,150	$9,000	N/A
Percentage of cost that is out of pocket:
Pediatric hernia/hydrocele repair	10%	10%	N/A
Pediatric fracture management	10%	10%	N/A
Pediatric laparotomy	10%	10%	N/A
Pediatric appendectomy	10%	10%	N/A
How many ongoing research projects involve children’s surgery (this may include quality improvement projects)?	1	1	1
How many ongoing research projects involve pediatric anesthesia?	1	1	1
How many ongoing research projects involve pediatric nursing?	0	0	0
How many workshops, trainings, and lectures related to pediatric surgery or perioperative care are in an average month?	0	0	0

^*Butaro has joint adult and pediatric recovery room. There are 6 beds that are shared between adult and pediatric patients. The shared recovery room has access to supplemental oxygen.

^**Rwinkwavu has an intensive care unit, but it is not specific for post-operative patients

Operative and Peri-Operative Facilities:

There were one to two functional operating rooms (ORs) per hospital. None of the hospitals had a dedicated children’s OR nor inpatient beds for children’s surgery or dedicated pediatric recovery room. BDH had six hospital beds in their adult recovery room that could be used by pediatric patients. RDH was the only hospital with a pediatric intensive care unit (ICU) with two pediatric ICU beds and eight neonatal ICU (NICU) beds. KDH had a NICU, with four NICU beds. Neither the ICU nor the NICU had functional pediatric ventilators. KDH had four functional neonatal ventilators. Between KDH and BDH, there were 15 monitors of which only three (20%) included all five of the following capabilities: electrocardiogram, blood pressure, pulse oximetry, temperature, and capnography. On average, there were 26 neonatal beds per hospital and an average of 5.7 pediatric warmers or incubators per hospital.

Referrals:

The average travel time to the nearest referral hospital was 1.5 hours. In 2022, the average number of patients referred from each site for surgical care was 13 children per year for patients under 5 years old and 19 children per year for patients 5-15 years old. The most common reasons for referral in patients under 5 years old were undescended testicle, fractures requiring imaging, and abscesses. In 5-15-year-old patients, the most common reasons were osteomyelitis and fractures requiring imaging. Patients under 5 years old accounted for 40% (n=38) of referrals.

Infrastructure:

All sites had a 24-hour emergency unit able to receive patients. Two out of three sites (BDH and KDH) had a trauma registry that included pediatric patients. All sites had a pediatric malnutrition feeding program, pediatric cognitive dosing aid, X-ray, and ultrasound. None of the sites had intravenous or enteral contrast for imaging. One site had anatomic pathology services.

Service Delivery:

Out of the 47 pediatric procedures deemed appropriate for a district level hospital on the CSAT_R, an average of 4.7 of them were adequately available (8 at BDH, 3 at KDH, 2 at RDH), 10.7 were available with limitations (19 at BDH, 4 at KDH, 9 at RDH), and an average of 31 were unavailable (19 at BDH, 38 at KDH, 36 at RDH). Across the three sites, 342 of these procedures were performed in 2022; An average of 25.7 (54.6%) of the 47 pediatric procedures deemed appropriate for a district level had never been performed. For these procedures, the most common barriers identified were limitations in availability of trained personnel (n=30.3, 64.5%), lack of personnel trained to perform the procedure at the site (n=17.3, 36.9%), and other (n=30, 63.8%%), with lack of an anesthesiologist (n=9, 19.1%) and lack of imaging/pathology services (n=6.7, 14.1%) as the most reported limitations for “other”.

SSORT Results:

Forty-seven respondents were interviewed (13 RDH, 21 KDH, 12 BDH) summarized in Table 2. Using a Likert scale (5=strongly agree), facility capacity (2.62/5), psychological safety (3/5), and resistance to change (1.53/5, where 5=high resistance) were identified as the three largest barriers to scaling up capacity for pediatric surgery across the three sites. Secondary barriers were communication about change (3.86/5), team efficacy (4.16/5), and leadership support (4.16/5). The lowest barriers were discrepancy (4.71/5), political governance context (4.71/5), team valence (4.72/5) and emotional reaction (4.71/5). The full SSORT results are summarized in Table 3.

Table 2.

SSORT Participant Demographics

	Butaro	Kirehe	Rwinkwavu
N	12	21	13
SSORT Participant Type
Surgeons	1	0	0
Medical Doctors	2	5	5
Anesthesiologist/Anesthetists	2	2	1
Nurse	4	8	4
Hospital Administration	1	3	3
Other Staff (Biomedical Engineers, Quality Improvement, Pharmacy)	2	3	0
Age
26-35	3	13	7
36-45	6	6	5
46-55	1	2	1
Sex
Female	1	3	6
Male	11	18	7
Years Working in Facility
<1 year	11	18	10
1-5 years	5	13	7
6-10 years	1	3	3
>10 years	1	3	3

Table 3.

SSORT Results Across Three District Hospitals

Domain	Domain Description	Score	IQR
Resistance to Change	Whether the individual may resist change	1.53	1-1
Facility capacity	Beliefs regarding organizational resource availability related to funds, human resources, equipment and supplies, infrastructure, and information management	2.62	1-4
Psychological Safety	Shared team belief that it is safe to take risks, characterized by interpersonal trust and respect	3.00	1-5
Communication about change	Attitudes towards facility-wide climate that supports learning and improvement	3.86	3-5
Team Efficacy	Team level belief in ability to perform necessary tasks successfully with respect to the proposed change	4.16	4-5
Leadership support	Facility members’ belief that formal leaders have explicitly bought in and support the proposed change	4.16	4-5
Vision for sustainability	Belief that the facility can sustain the proposed change long-term and institutionalize changes	4.26	4-5
Learning Environment	Attitudes toward facility-wide climate that supports learning and improvement	4.31	4-5
Team Learning Orientation	Shared team belief that team behaviors facilitate learning	4.33	4-5
Individual Efficacy	Individual belief that the person can perform necessary tasks successfully with respect to the proposed change	4.37	4-5
Individual Valence	Measures whether individual values the proposed change	4.49	4-5
Appropriateness	Belief that the proposed change is appropriate in addressing discrepancy	4.53	4-5
Discrepancy	Belief that facility is in need of change	4.71	5-5
Political governance context	Measures facility members’ attitudes toward political governance support regarding the proposed change	4.71	5-5
Team Valence	Measures whether the team values the proposed change	4.72	5-5
Emotional Reaction	Measures whether the individual feels positively toward the proposed change	4.75	5-5

Discussion

Inability to treat pediatric conditions at a district level results in an increased flow of patients to tertiary or referral centers. This heightened patient influx places a considerable strain on referral hospitals, leading to extended wait times and delayed care, ultimately resulting in worse patient outcomes. In a country like Rwanda, where there are only three pediatric surgeons, enhancing the capacity to handle minor procedures at the district hospital level can contribute significantly to the availability of existing surgeons.

In this study, we use the CSAT_R and the SSORT tool to assess the readiness and barriers to pediatric surgical capacity building in district hospitals in Rwanda. The CSAT_R revealed that all sites were performing minor pediatric procedures, but none was able to perform major pediatric surgeries as defined by the Optimal Resources for Children’s Surgery consensus guidelines.²⁵ Only 10% of district hospital level pediatric procedures were adequately available, and the main barriers were a lack an anesthesiologist at all sites and a surgeon at two sites.

Task shifting, or the use of non-specialists in performing tasks originally performed by surgeons and anesthesiologists may alleviate the need to hire additional workforce such as general surgeons.^26,27 This strategy may be effective for sedation or regional and local anesthesia and some minor surgical procedures such as circumcision or burn care. However, general anesthesia for patients under 5 years-old must be performed by a physician anesthesiologist in Rwanda, and general surgeons are still required to perform more invasive procedures at the district level. Policy makers and managers should engage in discussions to provide the district hospitals the necessary surgical and anesthesia capacity including an anesthesiologist, to enable access to timely, safe, and quality pediatric surgery. All hospitals had gaps in infrastructure and equipment required for pediatric surgical care, possibly secondary to a lack of a surgical workforce leading to insufficient surgical equipment investment. These findings are consistent with previous studies that have identified infrastructure and workforce as key determinants of the ability to provide high-quality surgical care in LMICs.^22,28

One constraint observed across all three sites was the absence of a comprehensive, standardized system for tracking surgical patients, referrals, and outcomes. In a resource-limited context, it may be even more important and immediately accessible to ensure appropriate and timely referral mechanisms to increase access to pediatric surgical care. All three hospitals utilized a mix of paper logs and online medical record systems, and each hospital employing a distinct reporting system. Ensuring reliable and consistent monitoring and evaluation of surgical patient outcomes is necessary to establish a baseline understanding of care capacity, to assess the effectiveness of interventions, and to determine areas that warrant prioritized hospital investment.

This study did not specifically assess hospitals based on the official health services package for district hospitals in Rwanda. Instead, expert consensus recommendations were utilized to determine what would be appropriate, safe, and vital to provide at the district hospital level in this context. As a result, our findings do not indicate absolute deficiencies in the required provision of care, but rather serve as indicators of potential areas for improvement that district hospitals and national ministries of health in East Africa can explore to optimize opportunities for enhancing children’s health at the district level.

The SSORT findings highlighted key organizational and team barriers to implementing change in the surgical setting. Fostering increased and open communication about proposed changes, for example through regular town-hall type meetings or presentations during monthly hospital staff meetings may be important strategies to address barriers related to psychological safety and resistance to change. Additionally, inviting employees and staff to give structured feedback through individual meetings or anonymous feedback boxes may promote an increased sense of ownership in the process. Although not extensively studied in existing literature, these findings emphasize the importance of addressing these organizational and team barriers prior to the implementation of surgical capacity-building interventions.

One of the strengths of this study was its comprehensive approach, which assessed both facility barriers and organizational barriers to increasing pediatric surgical capacity. Unlike previous studies that mainly focus on facility factors, this study examined team and individual beliefs prior to providing valuable insights for tailoring interventions to ensuring their success.

The study has several limitations and thus findings need to be interpreted within the study limits. Firstly, it was conducted at only three sites and thus the findings may not be generalizable to all district hospitals in Rwanda. Additionally, the three district hospitals included in this study are all supported by Partners In Health (PIH), which may provide a higher level of support and engagement in research activities and provision of additional resources that are not normally available at district hospitals in Rwanda. Moreover, while these three hospitals were rural, not all district hospitals in Rwanda are in rural areas. Finally, the use of self-reporting for the SSORT tool introduces potential bias and may affect the accuracy of the results.

Conclusion:

This study examined capacity for pediatric surgical care in three hospitals, revealing limited availability of specialized facilities and personnel. Addressing gaps in infrastructure and improving readiness to implement quality improvement interventions are necessary to expand surgical services and improve outcomes for pediatric patients in LMICs.

Appendix 1

Children’s Surgical Assessment Tool: For Rwanda District Hospitals*

*This tool was adapted from the Nigerian WHO-PGSSC-GICs Children’s Surgical Assessment Tool (publication in pre-print).^29,30

FACILITY CHARACTERISTICS
For children <5 years old:
	Total number of pediatric inpatient admissions (>6 hours in non-emergency ward) for children <5 in a year	#
	Total number of pediatric Emergency Department visits for children <5 in a year	#
	Total number of pediatric outpatient visits for children <5 in a year	#
	Total number of children’s surgical admissions for children <5 in a year	#
	Total number of children’s surgical outpatients (visits) for children < 5 seen in a year	#
For children 5-15 years old:
	Total number of pediatric inpatient admissions (>6 hours in non-emergency ward) for children 5-15 years-old in a year	#
	Total number of pediatric Emergency Department visits for children 5-15 years-old in a year	#
	Total number of pediatric outpatient visits for children 5-15 years-old in a year	#
	Total number of children’s surgical admissions for children 5-15 years-old in a year	#
	Total number of children’s surgical outpatients (visits) for children 5-15 years-old seen in a year	#
Facility Information:
	Total number of inpatient hospital beds dedicated to children’s surgery	#
	Does your hospital have a pediatric recovery room?	Y or N
	Total number of recovery room hospital beds dedicated to children’s surgery	#
	Is oxygen available in the recovery room?	Y or N or N/A
	Total number of operating rooms in the hospital	#
	Total number children’s operating rooms	#
	Total number of neonatal unit/special baby care unit beds	#
	Does your hospital have a post-operative ICU?
	Total number of pediatric ICU/advanced care beds	#
	Total number of neonatal ICU beds	#
	Total number of functional pediatric ventilators in the ICU	#
	Total number of functional neonatal ventilators in ICU	#
	Total number of functional incubators or pediatric warmers	#
	Total number of patient monitors in pediatric and neonatal ICU	#
	How many of these monitors include all of the following: EKG, blood pressure, pulse oximetry, temperature and capnography?	#
Access and referral systems:
	How many patients <5 years old per year do you refer to higher-level facilities for surgical interventions?	#
	How many patients 5-15 years old per year do you refer to higher-level facilities for surgical interventions?	#
	What is the most common reason for referral of pediatric surgical patients < 5 years old to higher levels of care?
	What is the most common reason for referral of pediatric surgical patients 5-15 years old to higher levels of care?
	How far away is the nearest referral hospital (hours, by car)	___ hours

INFRASTRUCTURE
General Infrastructure - How often is this item available and functional? Choose (tick) 0- Unavailable (NOT AVAILABLE under any circumstances); 1- Inadequate (available to LESS THAN HALF of the time); 2- Limited (available to MORE THAN HALF, of the time but not all of the time); or 3- Adequate (AVAILABLE all of the time without restrictions).		Unavailable (0)	Inadequate (1)	Limited (2)	Adequate (3)
	24-hour Emergency Unit able to receive pediatric patients
Pharmacy – product availability
	Pediatric malnutrition feeding program
	Pediatric dosing cognitive aid or guide
Radiology & Pathology – service availability
	Does your hospital have a radiologist?	Y or N
	Does your hospital have an anesthesiologist who can perform sedation?	Y or N
	Echocardiogram
	Ultrasound
	X-ray
	Anatomic Pathology services
Blood Supply - availability
	Blood component transfusion

SERVICE DELIVERY

In column 1 (procedure performed), indicate if the procedure is performed:  (a) Yes in all pediatric patients < 15  (b) Yes, but not in under 5 patients  (c) Yes, depending on complexity  (d) Yes, in emergency only or as temporizing measure  (e) No, never In column 3, Rate adequacy as below: 0- Unavailable (NOT AVAILABLE under any circumstances); 1- Inadequate (available to LESS THAN HALF of the time); 2- Limited (available to MORE THAN HALF, of the time but not all of the time) 3- Adequate (AVAILABLE all of the time without restrictions). Barriers: If Unavailable, Inadequate or Limited, (<3 in Adequacy column) please identify the barriers to access (check all that apply): Infrastructure - physical space, equipment or materials; Absent - has never has been present; Broken –resources present, but broken; Personnel - resource, service or function available, and staff trained, but limited availability at times (eg, night, weekend or holiday); Training – No staff trained in using resource or performing function; Stock out - cannot be procured, or required equipment or supplies out of stock often due to poor stock management practices or procurement failures; User fees - available, but out-of-pocket payment requirement prevents delivery for some; Other - Other factors (if “other,” please indicate in the box by writing the letter of which of the following best corresponds to the barrier).  • (A) Lack of anesthesiologist or general anesthesia  • (B) Lack of specialist (orthopedist, eye clinic etc)  • (C) Lack of imaging or pathology services  • (D) Other not specified (please list in comments)

SERVICE DELIVERY CONTINUED
		Procedure Performed	Total # performed/year	Rate (0-3)	Infrastructure	Absent	Broken	Personnel	Training	Stock Out	User Fees	Other
Procedures- Minor in patients <15 years old
	Suturing laceration
	Drainage of superficial abscess
	Wound debridement
	Biopsy (tumor)
	Male circumcision
	Management of non-displaced fractures
	Removal of foreign body from ear/nose
	Support for emergency airway obstruction
	Reduction of dislocation
	Reduction and application of splint for non-displaced fractures
	IV placement for neonates
Procedures – Major in patients < 15 years old
Children’s surgery
	Appendectomy
	Hernia/hydrocele repair
	Non-operative reduction of intussusception
	Operative reduction of intussusception
	Bowel resection
	Temporizing measures for gastroschisis and omphalocele (cover and rehydration) prior to referral
	Rectal biopsy
	Resection of solid abdominal masses
	Creation of intestinal stomas
	Emergency ostomies for imperforate anus
	Closures of intestinal stomas
	Resuscitation for pyloric stenosis
	Catheterization / suprapubic cystostomy
	Orchiopexy
	Repair of testicular or ovarian torsion
	Drainage of septic arthritis / osteomyelitis
	Repair of cleft lip and/or palate
Pediatric Resuscitation and Injury
	Emergency Surgical airway (cricothyroidotomy)
	Emergency Tube thoracostomy
	Trauma Laparotomy
	Conservative (non-operative) management for simple humeral fracture
	Open reduction and internal fixation
	Placement of pediatric external fixator
	Emergency Escharotomy/fasciotomy
	Contracture release
	Amputations
	Skin grafting
	Emergency Burr hole
	Emergency Craniotomy
Procedures - Advanced (<15 years old)
	Surgery for neonatal acute abdomen
	Repair of club foot

Surgical Volume
	Number of pediatric laparotomies (<5 y/o) performed last year	#
	Number of pediatric laparotomies (5-15 y/o) performed last year	#
	Number of elective hernia repairs (<5 y/o) last year	#
	Number of elective hernia repairs (5-15 y/o) last year	#
	Number of neonatal (< 1 month age) stomas performed last year	#
	Number of surgical repairs of pediatric (<5 y/o) open fractures performed last year	#
	Number of surgical repairs of pediatric (5-15 y/o) open fractures performed last year	#
	Total number of procedures performed in pediatric patients (<5 years) last year	#
	Total number of procedures performed in pediatric patients (5-15 years) last year	#
	Percent of <5 surgery cases that were emergent or urgent (non-elective) cases	%
	Percent of 5-15 surgery cases that were emergent or urgent (non-elective) cases	%
	At what age do you start performing elective hydrocele/hernia repair?	____ Years

Quality and Safety
	Is your institution involved in a formal training program for surgical trainees?	□ Yes □ No
	Does your institution have a method of monitoring surgical outcomes over time?	□ Yes □ No
	Does your institution use electronic medical records?	□ Yes □ No
	Does your institution have a trauma registry that includes pediatric trauma?	□ Yes □ No
	Number of post-operative pediatric (<5 y/o) in-hospital deaths last year	#
	Number of post-operative pediatric (5-15 y/o) in-hospital deaths last year	#
	Number of surgical site infections(SSIs) in pediatric patients (< 15 y/o) in the last year	#
	What is the highest ASA class of children operated at your institution? (ASA I = healthy patient, ASA II = patient with mild systemic disease, ASA III = patient with severe systemic disease, ASA IV = patient with severe systemic disease that is a constant threat to life)	□1 □2 □3 □4
	Is the WHO Surgical Safety Checklist used in the operating rooms for pediatric patients?	□ Never □ Less than half the time □ More than half the time □ All the time
	-Is pulse oximetry used in the operating rooms for pediatric patients?	□ Never □ Less than half the time □ More than half the time □ All the time
	How often does the hospital hold a surgical audit (Mortality and Morbidity conference) related to children’s surgical patients?	□ Never □ Every month □ As needed _______________ □ Every week □ Every quarter □ Other

Operating Equipment and Supplies – How often is the following equipment available and functional for surgery?
		Rate (0-3)	Infrastructure	Absent	Broken	Personnel	Training	Stock Out	User Fees	Other
	Functional anesthesia machines with pediatric breathing system
	Pediatric oropharyngeal airway (000–4)
	Pediatric endotracheal tubes (2.5 - 6 mm)
	Pediatric laryngoscope(Miller ≤ 2 or Macintosh ≤ 3)
	Pediatric facemask bag valve or Ambu bag (< 550ml bag with < size 3 mask)
	Pediatric difficult airway kit (LMA)
	Pediatric Magill forceps
	Pediatric blood pressure monitor or cuff
	Pediatric pulse oximetry
	Pediatric nasogastric Tube ( <12 Fr)
	Pediatric chest tubes (< 20 Fr)
	Pediatric surgical instruments
	Pediatric urinary catheters (<12 Fr)
	Pediatric central lines (< 7 Fr or 12 cm
	Sutures (3.0, 4.0, 5.0, 6.0)
	Capnography (exp. CO2 measurement)
	Pre-formed intestinal silos or pre-formed/readily available silos created from plastic bags

WORKFORCE
Children’s Surgery Provider Density
Providers		Full Time	Part Time
	Number of qualified general surgeons with pediatric exposure (trained surgeons with expertise in pediatric or neonatal surgery, but without formal subspecialty pediatric surgical training)	#	#
	Number of qualified general pediatric surgeons (trained surgeons with formal specialized training in children’s surgery of ≥ 1 year)	#	#
	Number of general doctors providing pediatric surgery (general practitioners without formal surgical training)	#	#
	Number of non-physicians providing pediatric procedure (non-physicians health care professional who performs procedures independently without formal training in surgery). These procedures include: circumcision, reduction of closed fractures, small wound repair, debridement, minor skin grafts.	#	#
	Number of qualified anesthesiologists	#	#
	Number of qualified pediatric anesthesiologists (trained anesthesiologists with formal specialization)	#	#
	Number of general doctors providing pediatric anesthesia (general practitioners without formal anesthesiology training)	#	#
	Number of non-physicians providing pediatric anesthesia (non-physicians health care professionals who perform pediatric anesthesia independently without formal training in anesthesia)	#	#
	Number of nurses with training or exposure in pediatric surgery, who treat only children
	Number of visiting or consultant physicians who are involved in pediatric surgical care (visiting at least 1x/week for at least 1 year).	Type _______________ # ____________ Type _______________ # ____________ Type _______________ # ____________

Please identify pediatric specialists that are available at your hospital (indicate number in brackets)
□ general pediatrician ( )
□ cardiac surgeon ( )
□ dental surgeon ( )
□ neurosurgeon ( )	□ neurologist ( )
□ ophthalmologist( ) (	□ respiratory physician ( )
□ orthopedic surgeon( )	□ neonatologist ( )
□ otorhinolaryngologist (ENT) ( )	□ cardiologist ( )
□ plastic surgeon ( )	□ endocrinologist ( )
□ urologist ( )	□ physiotherapist ( )
Please identify staff members that are present in your hospital (indicate number in brackets)
□ pediatric intensive care nurse ( )	□ radiographer ( )
□ neonatal nurse ( )	□ radiologist ( )	□ pathologist ( )
□ qualified nutritionist ( )	□ speech therapist ( )	□ oncologist treating children ( )
	□ audiologist ( )	□ ophthalmology technician ( )

Work Force Availability (How often are these available 24 hours a day?)		Unavailable (0)	Inadequate (1)	Limited (2)	Adequate (3)
	General surgeon or pediatric surgeon availability
	Pediatric anesthesia provider availability (with >6 months of training or exposure in pediatrics)

FINANCING
Health financing and accounting
	What percentage of children coming to this hospital have health insurance	□ None □ Fewer than half □ More than half □ All
	Nationally, is there government-sponsored health insurance/financing for children?	□ Yes □ No
	On average, what percentage pediatric surgical costs for patients are covered by insurance?	%
Budget Allocation
	Annual hospital budget allotted to children’s surgery and anesthesia □ N/A	Actual amount: % of total budget:
Cost: average total inpatient cost for a patient for…		Cost	% Out of Pocket
	pediatric hernia/hydrocele repair
	pediatric fracture management
	pediatric laparotomy
	Pediatric appendectomy
Average non-medical cost to a patient for a pediatric hernia/hydrocele repair (consider transport, lodging, food for patient and family)		Cost

TRAINING AND RESEARCH
	How many ongoing research projects involve children’s surgery (this may include quality improvement projects)?	#
	How many ongoing research projects involve pediatric anesthesia?	#
	How many ongoing research projects involve pediatric nursing?	#
	How many workshops, trainings, and lectures related to pediatric surgery or perioperative care are in an average month?	#