The Children’s Hospitals in Africa Mapping Project (CHAMP) survey: Facilities, equipment, supplies, infrastructure, and capacity to respond to emergencies

Vinayak Bhardwaj; Lawrence R Stanberry; Philip LaRussa; Wilmot James; Maitry Mahida; Aimable Kanyamuhunga; Atnafu Mekonnen Tekleab; Augustine Omoigberale; Crispen Ngwenya; David Musorewegomo; Dipesalema Joel; Ezekiel Mupere; Fidelis Ewenitie Eki-Udoko; Hannah Bousquet; Heloise Buys; Hilda Angela Mujuru; Ike Oluwa Lagunju; Irene Marete; Jethro Zawolo; Jonathan Kaunda Mwansa; Joseph Tawanda Chava; Maima Kawah Baysah; Mildred Anyango Mudany; Nancy Biyeah Yang Ngum; Nellie V T Bell; One Bayani; Pauline Samia; Ruth Nduati; Sam Miti; Schyler Zane Grodman; Thembisile Dintle Mosalakatane; Workeabeba Abebe; Ashraf Coovadia

doi:10.1371/journal.pgph.0005153

. 2025 Nov 26;5(11):e0005153. doi: 10.1371/journal.pgph.0005153

The Children’s Hospitals in Africa Mapping Project (CHAMP) survey: Facilities, equipment, supplies, infrastructure, and capacity to respond to emergencies

Vinayak Bhardwaj ^1,^#, Lawrence R Stanberry ^2,^#, Philip LaRussa ^2,^#, Wilmot James ^3,^#, Maitry Mahida ^2,^#, Aimable Kanyamuhunga ⁴, Atnafu Mekonnen Tekleab ⁵, Augustine Omoigberale ⁶, Crispen Ngwenya ⁷, David Musorewegomo ⁸, Dipesalema Joel ⁹, Ezekiel Mupere ¹⁰, Fidelis Ewenitie Eki-Udoko ⁶, Hannah Bousquet ², Heloise Buys ¹¹, Hilda Angela Mujuru ⁸, Ike Oluwa Lagunju ¹², Irene Marete ¹³, Jethro Zawolo ¹⁴, Jonathan Kaunda Mwansa ¹⁵, Joseph Tawanda Chava ⁸, Maima Kawah Baysah ¹⁴, Mildred Anyango Mudany ¹⁶, Nancy Biyeah Yang Ngum ¹⁷, Nellie V T Bell ¹⁸, One Bayani ⁹, Pauline Samia ¹⁹, Ruth Nduati ²⁰, Sam Miti ²¹, Schyler Zane Grodman ²², Thembisile Dintle Mosalakatane ⁹, Workeabeba Abebe ²³, Ashraf Coovadia ^24,^*,^#

Editor: Vinay Nair Kampalath²⁵

¹School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

²Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, United States of America

³School of Public Health, Pandemic Center, Brown University, Providence, Rhode Island, United States of America

⁴Pediatrics & Child Health Department, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda

⁵Department of Pediatrics and Child Health, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

⁶Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

⁷Department of Paediatrics, Faculty of Medicine, Midlands State University, Gweru, Zimbabwe

⁸Department of Child, Adolescent and Women Health, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe

⁹Department of Paediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana

¹⁰Department of Paediatrics and Child Health, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda

¹¹Department of Paediatrics & Child Health, University of Cape Town, Cape Town, South Africa

¹²Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria

¹³Department of Child Health and Paediatrics, School of Medicine, Moi University, Cheptiret, Kenya

¹⁴A.M. Dogliotti College of Health Sciences, University of Liberia, Congo Town, Monrovia, Liberia

¹⁵USAID Stop GBV Now Project, Zambia Center for Communication Programmes (Kwatu), Ministry of Health, Ndola, Zambia

¹⁶Independent Researcher, Help Reach Africa, Nairobi, Kenya

¹⁷Africa Medicine Regulatory Harmonisation Programme (AMRH), African Union Development Agency, AUDA-NEPAD, Pretoria, South Africa

¹⁸Department of Paediatrics, Ola During Children’s Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone

¹⁹Department of Paediatrics and Child Health, Medical College, Aga Khan University, Nairobi, Kenya

²⁰School of Medicine, College of Health Sciences, University of Nairobi, Nairobi, Kenya

²¹Department of Clinical Sciences, National Health Research and Training Institute (formerly known as TDRC), Ndola, Zambia

²²Division of Disaster Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America

²³Department of Paediatrics and Child Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

²⁴Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

²⁵University of Pennsylvania Perelman School of Medicine, UNITED STATES OF AMERICA

The authors have declared that no competing interests exist.

^✉

* E-mail: ashraf.coovadia@wits.ac.za

Contributed equally.

Roles

Vinayak Bhardwaj: Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Lawrence R Stanberry: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing

Philip LaRussa: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

Wilmot James: Conceptualization, Funding acquisition, Investigation, Supervision, Writing – review & editing

Maitry Mahida: Data curation, Formal analysis, Investigation, Visualization, Writing – original draft, Writing – review & editing

Aimable Kanyamuhunga: Investigation, Methodology, Writing – review & editing

Atnafu Mekonnen Tekleab: Investigation, Writing – review & editing

Augustine Omoigberale: Investigation, Methodology, Writing – review & editing

Crispen Ngwenya: Investigation, Methodology, Writing – review & editing

David Musorewegomo: Investigation, Writing – review & editing

Dipesalema Joel: Investigation, Writing – review & editing

Ezekiel Mupere: Investigation, Methodology, Writing – review & editing

Fidelis Ewenitie Eki-Udoko: Investigation, Writing – review & editing

Hannah Bousquet: Investigation, Methodology, Writing – review & editing

Heloise Buys: Investigation, Methodology, Writing – review & editing

Hilda Angela Mujuru: Investigation, Writing – review & editing

Ike Oluwa Lagunju: Investigation, Writing – review & editing

Irene Marete: Investigation, Writing – review & editing

Jethro Zawolo: Investigation, Writing – review & editing

Jonathan Kaunda Mwansa: Investigation, Methodology, Writing – review & editing

Joseph Tawanda Chava: Investigation, Writing – review & editing

Maima Kawah Baysah: Investigation, Writing – review & editing

Mildred Anyango Mudany: Investigation, Methodology, Writing – review & editing

Nancy Biyeah Yang Ngum: Investigation, Methodology, Writing – review & editing

Nellie V T Bell: Investigation, Writing – review & editing

One Bayani: Investigation, Writing – review & editing

Pauline Samia: Investigation, Writing – review & editing

Ruth Nduati: Investigation, Methodology, Writing – review & editing

Sam Miti: Investigation, Writing – review & editing

Schyler Zane Grodman: Investigation, Writing – review & editing

Thembisile Dintle Mosalakatane: Investigation, Writing – review & editing

Workeabeba Abebe: Investigation, Methodology, Writing – review & editing

Ashraf Coovadia: Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

Vinay Nair Kampalath: Editor

PMCID: PMC12654909 PMID: 41296752

Abstract

The Children’s Hospitals in Africa Mapping Project (CHAMP) survey was developed and implemented to assess the capabilities of some of the best resourced sub-Saharan African hospitals serving children. The aim was to evaluate hospital facilities, infrastructure, equipment, supplies, services, staffing, and readiness to care for children amid public health emergencies. This report analysed a subset of survey questions that characterised the hospitals and assessed facilities, equipment, supplies, infrastructure and capacity to respond to emergencies and outbreaks. Twenty-four sites were recruited. Twenty hospitals from 15 countries completed the survey from 2018 to 2019. This portion of the CHAMP study identified issues with facilities, equipment, supplies, infrastructure, and the capacity to respond to emergencies and infectious disease outbreaks. On a day-to-day basis, most hospitals were operating at or near capacity and frequently experienced power outages and water shortages. Overall, most hospitals were ill-prepared to manage a major disaster or infectious disease outbreak. If countries are to be prepared to deal with current needs as well as to prevent, detect, and rapidly respond to public health threats, hospitals that care for children will require significant investments.

Introduction

The Joint External Evaluation (JEE) tool was developed by the World Health Organization WHO) [1] to assist countries in assessing their capacities to prevent, detect and rapidly respond to public health threats. However, the tool does not incorporate an evaluation of where and how children are cared for in public health emergencies. Children account for about 25% of the world’s population [2] and have special vulnerabilities and needs in emergencies and infectious diseases outbreaks [3,4]. Children’s hospitals are often best prepared to meet the medical needs of children during emergencies and generally offer the most complex and comprehensive care for children available in a country [5]. The Children’s Hospitals in Africa Mapping Project (CHAMP) was developed to survey sub-Saharan African hospitals serving children, with the aim of evaluating hospital facilities, infrastructure, equipment, supplies, services, staffing and readiness to care for children amid public health emergencies. We have previously reported on CHAMP data detailing the available resources for diagnosis, treatment, and prevention of community acquired infections and the prevention, surveillance, and management of healthcare-associated-infections (HAIs) [6].

Methods

The study by Tarun [6] provided a description of the study sites, investigators, and the overall design of the multi-country study. Below we expand on the design and development of the survey.

Survey development

In August 2018, four members of the Columbia University’s Department of Pediatrics (the Columbia team) (S1 Table) convened a two-day meeting at Columbia Global Center in Nairobi with 25 individuals from 13 African countries who held hospital, medical school or healthcare-related leadership roles (S1 Table). Those invited to the meeting were known to the Columbia team or were identified through snowball recruitment by those known to the Columbia team. The healthcare leaders were not compensated or incentivized for their contributions to the survey. The meeting was convened to discuss the development of a survey to assess the readiness of hospitals in sub-Saharan Africa to respond to critical events such as epidemic outbreaks and mass casualties affecting children. While the term “Children’s Hospital” may imply a stand-alone facility that exclusively cares for children, during the meeting, the group developed a more practical designation of a CHAMPS “Children’s Hospital”, as facilities, either hospital building based, or ward based within hospitals, that focus on providing care to neonates, children and adolescents and are capable of providing a broad array of paediatric medical and surgical services, and are staffed by physicians and nurses dedicated to paediatric care with variable degree of formal paediatric training.

Over the two-day meeting, the participants expanded the scope of the survey to include other topics important in assuring children received the highest quality of care possible, e.g., the availability of malnutrition support services. A draft of the survey was shared with the meeting participants in late October for their feedback and subsequently revised and used for the study. The survey included yes/no questions, follow-up questions to further characterise yes responses, multiple choice questions, and free text. We did not seek to guide respondents to specific answers, and no responses were forced. The final survey consisted of 958 questions.

Site selection and survey implementation

We sought to recruit hospitals that met the CHAMP definition of a “Children’s Hospital”. Potential eligible sites were suggested by the Nairobi meeting participants, other colleagues with experience working in Africa, and by the study funder, the ELMA Foundation.

Survey responses were entered by each site’s investigator or delegate into a password-protected REDCap database managed by investigators at Columbia University Irving Medical Center (CUIMC). Site investigators were encouraged to ask other administrators at their hospital for assistance answering survey questions, e.g., asking the director of surgery about the number of operating theatres available for paediatric surgeries.

Sub-study survey questions

This sub-study focuses on survey questions relating to hospital characteristics, inpatient and outpatient facilities and normal capacity, surgical and radiology services, equipment and supplies, and infrastructure and capacity to respond to catastrophes and outbreaks. A future paper will deal with paediatric subspecialty services and staffing, laboratory services, and paediatric healthcare training needs.

Ethics review

Ethics review was conducted at both the local/country level and through CUIMC’s institutional review board (IRB) where it was required. Five sites required a formal ethics review. None of the ethics committees approached deemed this study to be human subject research. None of the participating sites needed written informed consent from site investigators and no patients were included or recruited to participate at any site in this study.

Statistical analysis

The percentage of positive responses for each survey question was calculated and reported. Microsoft Excel software was used for quantitative data analysis. We reported means, frequencies, ranges, and medians with interquartile range (IQR) where relevant.

Results

Study sites

Between September 2018 through June 2019, 24 hospitals agreed to participate in the CHAMP study, with 20 hospitals from 15 countries (Cameroon, Ethiopia, Ghana, Kenya, Lesotho, Liberia, Malawi, Nigeria, Rwanda, Sierra Leone, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe). completing the survey between December 2018 and November 2019.

Hospital characteristics

The characteristics of the hospitals surveyed are presented in Table 1. Sixteen hospitals described their designation as ‘national’, whilst one as ‘regional’, another as a paediatric university teaching hospital, one as a tertiary hospital and one as a zonal referral hospital. Seventeen described their institutions as tertiary care facilities, two as secondary care facilities, and one as a primary care hospital. Eight of 20 hospitals were free-standing children’s hospitals, and the other 12 were hospitals that had a separate facility or ward for paediatric patients. Nineteen of twenty hospitals were affiliated with a medical school. Sixteen of the hospitals accepted referrals from other hospitals, some of which were more than 50 km away. Nineteen of twenty hospitals surveyed reported the maximum age of children that were allowed for admission in their facilities. The median maximum age allowed for admission was 14 (range 12–18).

Table 1. Hospital characteristics.

Hospital Characteristics		% (n/N)^a
Designation	National hospital	94 (16/17)
	Regional hospital	6 (1/17)
	District hospital	0 (0/17)
Level of care*	Primary care	5 (1/20)
	Secondary care	10 (2/20)
	Tertiary care	85 (17/20)
Facility type	Public	80 (16/20)
	Private	5 (1/20)
	Public/private partnership	15 (3/20)
Affiliated with Medical School		95(19/20)
Free Standing Hospital		40 (8/20)
Separate Ward/Facility for Children		100(12/12)
Maximum Age of paediatric patients in children’s ward (IQR)		14 (3)
Age admitted to the adult ward, median (IQR)		15(1)
Accept referrals from other hospitals		80(16/20)
Number of paediatric patients accepted annually through referrals, median (IQR)		6850 (12924)
Up-referrals	Do not up-refer	25 (5/20)
	Only within the country	60 (12/20)
	Internationally	15 (3/20)

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^a n = positive responses and N = number of hospitals responding to survey questions.

Inpatient facilities

All 20 respondents reported having a separate paediatric in-patient area, and 3 also reported having a separate ward, or facility for adolescents (Table 2). The median number of paediatric beds was 172, and the average daily bed occupancy rate was 87%. The most common causes of high monthly admissions were malaria, respiratory tract infections, diarrheal diseases, meningitis, and malnutrition.

Table 2. General inpatient wards.

General Inpatient Wards	% (n/N)^a
Has a separate paediatric inpatient area	100 (20/20)
Number of beds, median (IQR)	172 (171)
Average bed occupancy rate, median (IQR)	87 (27)
Sometimes necessary to put more than one child in a bed	75 (15/20)
Has adequate number of beds	15 (3/20)
Number of additional beds needed, median (IQR)	50 (29)
Has protocol for Isolation and cohorting	35 (7/20)
Number of Isolation Rooms, median (IQR)	2 (5)
Has capacity to cohort patients in an infectious disease emergency	55 (11/20)
Inpatient Surge Capacity
In a catastrophic event accepts patients above maximum capacity	60 (12/20)
Paediatric inpatient surge capacity elsewhere	25 (3/12)

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^a n = positive responses and N = number of hospitals responding to survey questions.

When asked how often the general paediatric wards reached 100% capacity in the past year the most common answers were “almost always”, and “most of the time”. Fifteen of the 20 hospitals (75%) reported that admitting more than one child in a bed was often necessary. When asked how often that occurred, nine facilities reported daily, one reported weekly, one monthly, three seasonally (e.g., during malaria season), and one reported it occurring rarely. Three hospitals (15%) reported they had an adequate number of beds to meet current needs.

All 20 hospitals reported a paediatric intensive care unit (PICU) (Table 3 and S2 and S3 Tables). Twelve (60%) reported that they had a separate paediatric unit (PICU) (Table 3), and 12 (60%) reported that their institution had a separate neonatal intensive unit (NICU) (Table 4). Six hospitals had an adult ICU that allocated space for children (S2 Table), and five had a combined NICU/PICU (S3 Table). For the hospitals with a separate PICU (Table 3), the median number of beds was 6 (range, 3–16) The median bed occupancy rate was 83%. Only 1 (8%) of the 12 hospitals reported having an adequate number of PICU beds to meet their needs.

Table 3. Paediatric Intensive Care Unit (PICU).

Paediatric Intensive Care Unit (PICU)	% (n/N)^a
Number of hospitals with dedicated PICUs	60 (12/20)
Number of Beds in the PICU, median (IQR)	6 (3.75)
Average daily census of paediatric patients, median (IQR)	5 (1.25)
Average Bed Occupancy rate, median (IQR)	82.5% (21.25)
Has an adequate number of beds in the PICU to meet current needs	8.34 (1/12)
Additional beds are needed for paediatric patients, median (IQR)	5 (8)
Isolation rooms in the PICU	25 (3/12)
PICU Surge Capacity
Surge Capacity in PICU	27.3 (3/11)
PICU surge capacity elsewhere	0 (0/8)
In an infectious disease emergency has the capacity to cohort paediatric patients in a PICU	8.3 (1/12)
Can cohort paediatric patients in need of intensive care elsewhere	33 (3/9)

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^a n = positive responses and N = number of hospitals responding to survey questions.

Table 4. Neonatal Intensive Care Unit (NICU).

Neonatal Intensive Care Unit (NICU)	% (n/N)^a
Number of hospitals with dedicated NICUs	60 (12/20)
Number of beds in the NICU, median (IQR)	17.5 (34)
Average daily census of paediatric patients, median (IQR)	26 (36.5)
Average Bed Occupancy rate, median (1QR)	100 (5)
Has an adequate number of beds in the NICU to meet current needs	8.3 (1/12)
Additional beds are needed for paediatric patients, median (IQR)	20 (17.5)
Isolation rooms in the NICU	16.7 (2/12)
NICU Surge Capacity
Surge Capacity in NICU	16.7 (2/12)
NICU surge capacity elsewhere	0 (0/10)
In an infectious disease emergency has the capacity to cohort paediatric patients in a NICU	25 (3/12)
Can cohort paediatric patients in need of intensive care elsewhere	33 (3/9)

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^a n = positive responses and N = number of hospitals responding to survey questions.

For the hospitals with separate NICUs, the median number of beds was 17.5 (range, 4–50) the average daily census was 26, with an average bed occupancy of 100% (Table 4). The average number of additional beds needed was 20.

In addition to general inpatient wards, PICUs, and NICUs; respondents described other types of inpatient spaces where patients received care, including high-dependency cubicles, high-care bays, step-down units, resuscitation units, and surgical inpatient units. Data on the malnutrition wards can be found in S4 Table.

The most cited areas requiring more beds were general paediatric wards, surgical wards, NICU, PICU, emergency room, and malnutrition, renal, cardiac, oncology, and sickle cell wards.

Barriers to adding more beds included the lack of space, funding and inadequate numbers of healthcare providers to staff the extra beds (S5 Table).

Outpatient facilities

All but one of 20 hospitals (95%) had a general paediatric outpatient care area separate from the adult area (Table 5). Most patients (80%) were seen within 1–3 hours of presenting but waits could be as long as 8–24 hours. The average number of paediatric outpatients (18 responses) seen on a given day was 119 (range 35–300), and the highest number of paediatric outpatients (14 responses) seen in one day in the past year was 156 (range 40–612). The causes of the high volume included malaria, gastroenteritis, acute respiratory infections, pneumonia, burns, accidents, bronchiolitis and bronchitis, and evaluation of newborns for sepsis and neonatal jaundice.

Table 5. Paediatric outpatient area.

Paediatric Outpatient Area		% (n/N)^a
Has separate paediatric outpatient area (251)		95 (19/20)
Average number of paediatric patients seen in the outpatient area on a given day, median (IQR) (255)		55 (102.5)
The highest daily census of paediatric patients in the outpatient area in the past year, median (IQR) (256)		80 (131.75)
Wait time to be seen in the Outpatient Department (264)	< 1 hour	10 (2/20)
	1-3 hours	80 (16/20)
	4-8 hours	5 (1/20)
	8-24 hours	5 (1/20)
	> 24 hours	0 (0/20)
Outpatient Surge Capacity
Surge capacity for paediatric patients in the outpatient area (258)		50 (10/20)
Paediatric outpatient surge capacity elsewhere (260)		10 (1/10)

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^a n = positive responses and N = number of hospitals responding to survey questions.

Eighteen of the 20 hospitals (90%) reported having a separate paediatric emergency area (Table 6), distinct from the adult emergency area. The percent median number of beds in the paediatric emergency areas was 12 (range, 3–60). The average daily number of paediatric patients seen in the emergency area was 33, and the average daily census in the emergency area in the past year was 60. Seventy percent of the responding facilities had a mechanism to quickly identify and isolate patients with contagious diseases as they entered the emergency area. Fourteen of 20 hospitals (70%) reported that the wait time in the emergency area was less than one hour.

Table 6. Paediatric emergency room capacity.

Paediatric Emergency Room Capacity.		% (n/N)^a
Has a separate paediatric emergency (casualty) area		90 (18/20)
Number of beds are in the paediatric emergency (casualty) area, median (IQR)		12 (7.5)
Average number of paediatric patients seen in the emergency (casualty) area on a given day, median (IQR)		32.5 (66.75)
The highest daily census in the emergency (casualty) area in the past year, median (IQR)		60 (128)
The most common reasons for high usage were malaria, gastroenteritis, and respiratory infections
Has a mechanism (screen and triage) to quickly identify and isolate patients with contagious diseases as they enter the emergency (casualty) area		70 (14/20)
Wait time to be seen in the ER	< 1 hour	70 (14/20)
	1-3 hours	25 (5/20)
	4-8 hours	5 (1/20)
	8-24 hours	0 (0/20)
	> 24 hours	0 (0/20)
Paediatric Emergency Area Surge Capacity
Surge capacity for paediatric patients in the emergency area		35 (7/20)
Paediatric emergency surge capacity elsewhere		14.3 (2/14)

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^a n = positive responses and N = number of hospitals responding to survey questions.

Isolation rooms and capacity to cohort patients and surge

In the general inpatient wards 19 hospitals (95%) reported that the median number of isolation rooms was 2 (Table 2). In an infectious disease emergency, 11 (55%) hospitals had the capacity to cohort patients in their general inpatient units and 7 (35%) hospitals reported a standard operating procedure for cohorting and isolating patients. In the event of a catastrophe, e.g., Cholera outbreak, chemical poisoning, 12 hospitals (60%) reported they had surge capacity in their general paediatric wards and 3 of 12 hospitals (25%) reported they had surge capacity elsewhere. When asked, “How do you accommodate excess patients?” the responses included, add “more beds”, “vacate stable patients”, “open up an isolation unit/holding bay not in regular use”, “make use of the short stay ward”, “have patients share beds”, “use the floor”, or “use a separate shelter outside the main hospital”.

In hospitals with a dedicated PICU, 3 of 12 (25%) reported having Isolation rooms (Table 3). Three of 11 hospitals (27%) reported having surge capacity in the PICU. In an infectious disease emergency 1 hospital (8.3%) reported the capacity to cohort paediatric patients in the PICU.

In the 12 hospitals with dedicated NICUs, 2 (17%) reported having isolation rooms, 3 (25%) had the capacity to cohort patients, 2 (17%) had surge capacity within the NICU and 3 of 9 hospitals (33%) also reported having the capacity to provide intensive care elsewhere (Table 4).

Seven (35%) reported having surge capacity in the emergency area, and two of 14 respondents (14%) described paediatric emergency surge capacity elsewhere within the facility.

Ten of 20 hospitals (50%) had surge capacity for paediatric outpatient care (Table 5).

Staffing during catastrophic events

If a catastrophic situation exceeded staff capacity to care for children, 19 of 19 hospitals (100%) reported the following overlapping response strategies: pulling additional staff from other services, recalling staff from leave, making do with existing resources, recruiting from other centres, and diverting patients to other hospitals. When asked how many times in the past month the paediatric services have been put on diversion (i.e., closed to new admissions because the facility has reached the maximum number of patients that could be cared for), 15 hospitals answered as follows: never (12), 1–2 days (1), 4 days (1), and several times (1).

Disaster response program

Ten of 19 hospitals (53%) had a disaster response program, 11 of 19 (58%) had a disaster response plan, and 6 of 19 (32%) conduct disaster simulations and/or drills (S6 Table). Fifteen of 19 hospitals (79%) reported that disaster response coordination was a Ministry level function.

Eleven of 19 hospitals (58%) had a disaster response team, and 17 hospitals (85%) identified their within-facility methods of disaster communication (S6 Table).

Information regarding disaster funding can be found in (S6 Table).

When asked, “Do you have a policy for treating children in the absence of a parent or guardian?” 10 of 18 (56%) answered yes.

Surgical services

The survey asked three yes or no questions regarding how patients needing surgery were managed: (1) did they perform surgery on children in their facility, (2) did they up-refer to children for surgery to other hospitals in their network, and (3) did they up-refer outside their network (Table 7). Of the 20 hospitals, 17 (85%) reported performing surgery on children in their facility. Seven hospitals (35%) reported up-referring children for surgery to other hospitals within their network, and 4 (20%) up-referred outside their network of hospitals.

Table 7. Surgical services.

Surgical Services		% (n/N)^a
Places where Paediatric Surgery is performed	Performed in your hospital	85 (17/20)
	Up referred to another hospital in your network of hospitals	35 (7/20)
	Up referred to a hospital outside of your network of hospitals	20 (4/20)
Number of dedicated paediatric operating theatres that are available daily, median (IQR)		2 (2)
Number of general (adult/paediatric) operating theatres that can be used for paediatric surgery, median (IQR)		2 (2)
Has an adequate number of operating theatres to meet your current needs for paediatric surgery		20 (4/20)
Number of additional operating theatres that are needed, median (Range)		2 (1 –6)
Average number of paediatric surgeries performed per week, median (IQR)		12 (20.5)
Wait time for an elective surgery	< 1 week	11.1 (2/18)
	1 week - 1 month	33.3 (6/18)
	1-3 months	11.1 (2/18)
	3-6 months	27.8 (5/18)
	> 6 months	11.1 (2/18)

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^a n = positive responses and N = number of hospitals responding to survey questions.

There were a median of two paediatric operating theatres available daily, and the median number of additional theatres needed was two. Only four of 20 hospitals (20%) reported having an adequate number of operating theatres to meet current paediatric surgery needs.

The average wait time for elective surgery was variable, with the longest wait time of more than 6 months in 2 of the 18 hospitals and the shortest wait time of less than 1 week in 2 of the hospitals. S7 Table lists the types of anaesthetic agents used and the methods for sterilizing reusable equipment and administering anaesthetic agents.

Radiology services and equipment

All hospitals had X-ray and ultrasound machines, 70% had CT scanners, and 50% had MRI scanners. S8 Table provides more details on radiology services.

PICU and NICU equipment and maintenance

Of the 12 hospitals that had separate PICU, all had pulse oximetry, 11 (92%) had oxygen cylinders, and 8 (67%) had continuous positive airway pressure (CPAP) machines. Of the 8 hospitals (67%) with mechanical ventilators (66%), the median number of ventilators was 4, with a median number of 3 functional on any given day. (Table 8). Other PICU equipment is listed in Table 8.

Table 8. PICU Equipment.

Available Equipment, Supplies or Procedures	% (n/N)^a
Pulse oximeters	100 (12/12)
Continuous ECG monitors	50 (6/12)
Invasive pressure monitors	16.7 (2/12)
Mechanical ventilators	66.7 (8/12)
CPAP machines	66.7 (8/12)
Oxygen concentrators	41.7 (5/12)
Oxygen cylinders	91.7 (11/12)
Peritoneal dialysis	58.3 (7/12)
Haemodialysis machine	8.3 (1/12)
Cooling devices for induced hypothermia	0 (0/12)
High frequency oscillators (HFVO)	0 (0/12)
EEG monitors	8.3 (1/12)
Ultrasound machines	58.3 (7/12)
Phototherapy lights	58.3 (7/12)
Central line insertion and maintenance	33.3 (4/12)
Number of Machines	Median (IQR)
Number of mechanical ventilators	4 (1.5)
Number of functional mechanical ventilators	3 (2.5)
Number of CPAP machines	2 (1)
Number of functional CPAPs machines	1.5 (2)
Number of Oxygen Concentrators in the ICU	2 (0)
Number of Oxygen Cylinders in the ICU	4 (2.5)
Number of functional Oxygen Concentrators in the ICU	2(2)

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^a n = positive responses and N = number of hospitals responding to survey questions.

Of the 12 hospitals with dedicated NICUs, all had phototherapy lights and CPAP machines, 11 (92%) had pulse oximeters and oxygen cylinders. Of the five hospitals (42%) with mechanical ventilators, the median number of machines was 2, with a median of one functional ventilator on any given day (Table 9). Other NICU equipment is listed in Table 9.

Table 9. NICU Equipment.

Available Equipment, Supplies or Procedures	% (n/N)^a
Pulse oximeters	91.7 (11/12)
Continuous ECG monitors	25 (3/12)
Invasive pressure monitors	0 (0/12)
Mechanical ventilators	41.7 (5/12)
CPAP machines	100 (12/12)
Oxygen concentrators	58.3 (7/12)
Oxygen cylinders	91.7 (11/12)
Peritoneal dialysis	0 (0/12)
Haemodialysis machine	0 (0/12)
Cooling devices for induced hypothermia	8.3 (1/12)
High frequency oscillators (HFVO)	0 (0/12)
EEG monitors	0 (0/12)
Ultrasound machines	33.3 (4/12)
Phototherapy lights	100 (12/12)
Central line insertion and maintenance	33.3 (4/12)
Number of Machines	Median (IQR)
Number of mechanical ventilators	2 (5)
Number of functional mechanical ventilators	1 (5)
Number of CPAP machines	5 (6)
Number of functional CPAPs machines	5 (6)
Number of Oxygen Concentrators in the ICU	3 (2.5)
Number of Oxygen Cylinders in the ICU	3 (2.5)
Number of functional Oxygen Concentrators in the ICU	4 (9)

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^a n = positive responses and N = number of hospitals responding to survey questions.

The five hospitals with Combined NICU/PICUs had a similar equipment and supply profile as found in hospitals with separate NICUs and PICUs but data were lacking on number of mechanical ventilators (S9 Table).

Fourteen of 19 (74%) hospitals reported having equipment maintenance programs. Examples of equipment maintained included mechanical ventilators and other ICU equipment (13), anaesthesia equipment (13), infant incubators (12).

Medical supplies

Thirteen of 19 hospitals (68%) reported not having adequate medical supplies to meet current paediatric needs, and 6 of 19 (32%) reported they reused disposable medical supplies. The most common supplies and medications in short supply included endotracheal tubes appropriate for infants and children (63%), sterile surgical gloves (53%), commonly used antibiotics (47%), oxygen (42%), Insulin (32%), antimalarial drugs (26%), syringes and/or needles appropriate for paediatric use, saline (21%) and recommended paediatric vaccines (21%) (S10 Table). Five of 18 hospitals reported that they also experienced supply shortages during periods of extreme heat, most commonly sterile gloves, IV catheters, and IV fluids. Other items mentioned that were frequently in short supply were medical equipment, mechanical ventilators, and monitors. The most reused single-use items were nasal prongs, face masks, nebulizing kits, pulse oximetry probes, endotracheal tubes, suction tips, tympanic membrane temp covers, and insulin syringes.

Infrastructure

Sixteen of 19 (84%) hospitals reported having blackouts in their power supply with 19 of 19 reporting they have emergency generators. Eleven of 19 hospitals (58%) reported interruptions in their water supply. The frequency of power and water interruptions is presented in Table 10. Only one hospital reported never having experienced blackouts.

Table 10. Infrastructure.

Infrastructure		% (n/N)^a
Electricity
Number of hospitals that experience blackouts		78.9(15/19)
Frequency of blackouts	Daily	13.3 (2/15)
	Weekly	26.7 (4/15)
	Monthly	13.3 (2/15)
	Infrequently	46.7 (7/15)
Number of hospitals that have emergency generators		100 (19/19)
Frequency at which generators are used during a blackout	Always	84.2 (16/19)
	Sometimes	15.8 (3/19)
	Rarely	0 (0/19)
Number of hospitals that experience other fluctuations in power supply, e.g., power drops, surges, blackouts)?		68.4 (13/19)
Water Supply
Number of hospitals reporting the frequency of interruptions in water supply		52.6 (10/19)
Frequency of interruptions to the water supply	Daily	50 (5/10)
	Weekly	20 (2/10)
	Monthly	10 (1/10)
	Infrequently	20 (2/10)

Open in a new tab

^a n = positive responses and N = number of hospitals responding to survey questions.

Six of 18 hospitals (33%) reported that their institution exclusively used a paper system for medical records, while 14 of 19 hospitals (74%) reported using a hybrid (electronic and paper) system. None exclusively used an electronic system. Of the 14 hospitals using an electronic system, 13 (93%) reported that they could selectively search the system for specific information.

Discussion

This part of the CHAMP study characterized the 20 participating hospitals and assessed their facilities, infrastructure, equipment, and capacity to respond to catastrophic emergencies and infectious disease outbreaks.

The 20 hospitals included in this study were national, regional, public, tertiary, and referral hospitals 19 of which were affiliated with medical schools. Given their status, these institutions would be among the leading children’s hospitals in their country.

The hospitals had substantial general paediatric ward capacity with a median of 172 beds. Specialized units to provide intensive care to neonates and children were available at 85% of CHAMP hospitals. Our findings, regarding the capacity to provide critical care differ from those of the PediPIPES survey of 37 hospitals in 10 West African hospitals [7]. While the percentage of tertiary facilities was similar for the two studies (85% of CHAMP hospitals versus 87% of PediPIPES facilities), only 43% of the PediPIPES facilities had a NICU or a general intensive care unit, suggesting that the lack of paediatric critical care services for infants and children in Africa is likely greater than observed in our study. A dedicated paediatric emergency room was available at 90% of CHAMP hospitals and most had the ability to quickly identify and isolate patients with suspected infectious diseases. Surgical services and radiological services were available at most hospitals. Regarding radiology equipment, ultrasound and x-ray machines were available at all hospitals and CT and MRI scanners at 70% and 50% of hospitals, respectively. In the 12 hospitals with a separate PICU, all had pulse oximetry, and 67% had mechanical ventilators. In the 12 hospitals with separate NICU, all had CPAP machines and phototherapy lights, and 92% had pulse oximeters. Only about 50% of hospitals had mechanical ventilators, like the PediPIPES hospitals with intensive care units.

Most hospitals faced significant challenges in meeting their current clinical demands, often exceeding bed capacity across general paediatric and specialty paediatric wards, intensive care units, and the emergency room. Bed shortages often necessitated putting more than one child in a bed or crib, posing a risk of hospital-acquired infections, a problem recognized in another study [8]. Eighty percent of hospitals did not have enough operating theatres to meet current needs.

Hospitals also had infrastructure challenges with unreliable sources of power and water, findings similar to those of other published studies [7,9]. Most hospitals reported power outages, a problem predicted to worsen with climate change [10]. Over half the hospitals reported interruptions in their water supply. The availability of a reliable water source is a key component of the WHO’s special focus on WASH (water, sanitation, hygiene and health) and infection prevention and control [11]. Investments are needed to ensure hospitals have adequate reliable energy and water supplies that are resilient to damage caused by climate change.

Additional challenges that would impede the CHAMP hospitals in addressing a catastrophe or epidemic included limited numbers of isolation rooms, inability to cohort patients, lack of standard operating procedures for isolation and cohorting, and limited capacity to surge.

Forty-one percent of the Sub-Saharan African population is under 15 years of age, some 593 million children in 2024, with a projection of 734 million children by 2043 [12,13]. Our findings and the projection of continued growth in the size of the paediatric population indicate there is a critical need to invest in facilities, infrastructure, and equipment. The ability to add additional hospital beds is partly limited by an inadequate supply of doctors and nurses. Africa already faces a shortage of healthcare workers [14], and the supply of paediatricians is woefully inadequate. In high-income countries, the median number of paediatricians per 100,000 children is 72, while in Africa, it is 0.5 per 100,000 children [15]. Essential to improving African hospitals that care for children will be the training of many paediatric physicians, surgeons, nurses and other paediatric healthcare workers.

This study had some important limitations. The hospitals that were included in this study were highly selected and not all invited hospitals responded. Four hospitals that agreed to participate did not complete the surveys. We recognized that this group of hospitals were not representative of most African hospitals where children might receive care. Indeed, we expect that most hospitals where children might receive care have greater challenges and fewer resources than the hospitals in our study. Not all hospitals answered every question. There was no verification of the responses. The survey was conducted at one point in time prior to the COVID-19 pandemic. The determination of ‘adequate’ or ‘inadequate’ resources was subjective as these were left to the discretion of the site that completed this survey.

Conclusions

This study determined that the CHAMP hospital facilities, equipment, supplies and infrastructure were inadequate to support routine clinical demands. The hospitals were, by and large, ill-prepared to respond to public health emergencies affecting children. Greater investments in African hospitals that care for children and in the training of paediatric healthcare workers should be a high priority for governments and donors. Not only is it the right thing to do [16], but it is good economics [17–23]. The CHAMP survey tool (S1 Appendix) is available and might be useful in identifying and prioritizing investments. As regards hospital readiness to deal with health emergencies we recommend the adoption of established international standards such as the WHO Hospital Emergency Response Checklist or the Essential Emergency and Critical Care (EECC) framework [24,25].

Finally, investments that strengthen and grow children’s hospitals will help ensure that African children are afforded the right recognized in Article 24 of the United Nations Convention on the Rights of the Child, “to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health” [26].

Supporting information

S1 Appendix. Redcap Survey Tool.

(DOCX)

pgph.0005153.s001.docx^{(714KB, docx)}

S1 Table. Nairobi Meeting Attendees.

(DOCX)

pgph.0005153.s002.docx^{(19.8KB, docx)}

S2 Table. Adult ICU Capacity.

(DOCX)

pgph.0005153.s003.docx^{(17.1KB, docx)}

S3 Table. Combined NICU/ PICU Capacity.

(DOCX)

pgph.0005153.s004.docx^{(17.4KB, docx)}

S4 Table. Malnutrition Ward.

(DOCX)

pgph.0005153.s005.docx^{(16.9KB, docx)}

S5 Table. Reasons that prevent adding additional beds.

(DOCX)

pgph.0005153.s006.docx^{(18.1KB, docx)}

S6 Table. Disaster Response.

(DOCX)

pgph.0005153.s007.docx^{(19.4KB, docx)}

S7 Table. Anaesthetic Agents.

(DOCX)

pgph.0005153.s008.docx^{(18.8KB, docx)}

S8 Table. Radiology Services.

(DOCX)

pgph.0005153.s009.docx^{(18.4KB, docx)}

S9 Table. Combined NICU/ PICU Equipment and Supplies.

(DOCX)

pgph.0005153.s010.docx^{(17.6KB, docx)}

S10 Table. Medical Supplies.

(DOCX)

pgph.0005153.s011.docx^{(17.5KB, docx)}

S1 Data. Quantitative Data of the Survey.

(XLSX)

pgph.0005153.s012.xlsx^{(55.5KB, xlsx)}

S2 Data. Qualitative (Free Text) Data of the Survey.

(XLSX)

pgph.0005153.s013.xlsx^{(105.8KB, xlsx)}

Acknowledgments

We would like to thank Dr. Murugi Ndirangu and Ms. Pauline Winfred Muthoni of the Columbia Global Center— Nairobi for helping arrange the August 2018 CHAMP organizing conference and for countless other activities and services that were essential in conducting this study. We also wish to thank Noël Manu, the Columbia University Administrative Coordinator at the time, for her exceptional work in coordinating countless efforts critical to the success of the project. We want to acknowledge the hospital staff who helped gathered this information. We also wish to thank the ELMA Foundation for their financial support of this project.

Data Availability

The data underlying this study are available in full in the Supporting Information files submitted with this manuscript. All survey responses used in the analysis have been anonymized and aggregated to protect the identities of participating institutions and individuals. The data is shared as supplemental information as two files – ‘CHAMP File quantitative Data’ and ‘CHAMP Free Text’.

Funding Statement

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the EMLA Foundation (institutional grant to PL; WJ; and LS). There was no number associated with the grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0005153.r001

Decision Letter 0

Vinay Kampalath

10 Jul 2025

PGPH-D-25-01272

The Children’s Hospitals in Africa Mapping Project (CHAMP) Survey: Facilities, Equipment, Supplies, Infrastructure, and Capacity to Respond to Emergencies.

PLOS Global Public Health

Dear Dr. Coovadia,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 09 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Vinay Nair Kampalath, MD, MSc, DTM&H

Academic Editor

PLOS Global Public Health

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Thanks for this important contribution. The development of paediatric capacity in Africa is important, particularly as it is relevant to healthcare facilities' capabilities to respond to emergencies. This contribution is vitally important, but we invite you to submit a revision that takes into account the reviewers' comments. In particular, I want to highlight Reviewer 2's extensive feedback on how some restructuring of the paper will strengthen the results and conclusions.

In your revision, please highlight how you've addressed both Reviewers 1 and 2's comments.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Global Public Health’s publication criteria?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?-->?>

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: The 'survey development' section should be described in more detail: please define 'healthcare leaders' and 'team from Columbia'. How were the 13 African countries selected? Were the healthcare leaders compensated or incentivized for their contributions to the survey? Additionally, how were the surveyed hospitals selected? Purposive sampling, snowball technique...?

The overall goal of the survey seems to conflict itself at times: initially it is described as an assessment of pediatric readiness during mass casualties and epidemic outbreaks. However, later the participants expanded the scope of the survey to include quite broad measures, like "highest quality of care" and "malnutrition support services." If the scope was just overall pediatric readiness, and not specifically emergencies or mass casualties, the title and abstract should be changed to reflect this.

Please give more information about the IRB process, including the five sites where review was required and protocol number. In line 144, define "CIUMC".

Line 184 seems irrelevant to this study's aims of emergency preparedness: "The most common causes of high monthly admissions were malaria, respiratory tract infections, diarrheal diseases, meningitis, and malnutrition." Lines 228-230 is similar, where if you're talking about emergency preparedness, I don't know that high daily volumes from pneumonia is applicable. Table 6 is similar "most common reasons for high ER usage": if you're trying to connect common diagnoses as potential areas for offloading during a surge, you need to explicitly state that. Otherwise this data seems like it belongs in a different publication.

In Table 2, define "SOP."

Line 205 has a typo: " For the hospitals with separate NICUs, the average number of beds was 17. 5 (range, 4-50)

the average daily census was 26, with an average bed occupancy of 100% (Table 4)."

Table 7: I don't see how average wait time to elective surgery pertains to mass casualties and emergency preparedness.

Line 358 has two periods.

Line 438-439: "Not only is it the right thing to do, but it is good economics." This is an important point that needs to be much more clearly emphasized. Give statistics on how much money is saved by investing in quality pediatric care.

In the limitations section, you state that not all hospitals answered every question. Please include response rates by percentages - the questions that are left unanswered also yield important data.

Reviewer #2: The title addresses a relevant and important topic, particularly for pediatric healthcare in sub-Saharan Africa. The following comments are intended to help strengthen the manuscript’s quality, clarity, and scientific rigor.

Major Comments

1. Sample Size and Selection Criteria

The study does not clearly describe how the 20 hospitals were selected by the participants in Nairobi. The note that “Potential eligible sites were suggested by the Nairobi meeting participants” requires further explanation — detailing how, when, and based on what criteria these sites were proposed, and whether this process introduced selection bias.

Moreover, the fact that 95% (19/20) of the surveyed hospitals are affiliated with medical schools suggests that the sample largely consists of teaching hospitals. This should be acknowledged as a limitation, as it affects the representative of the findings for the broader landscape of hospitals in Africa.

2. Clarification of Terminology

The term “Children’s Hospital” may give the impression that Africa has many stand-alone pediatric hospitals, which is not the case in most countries. The authors should try another wording than children hospital as it gives wrong impression that these hospitals were standalone pediatric hospitals even if it is operational defined

3. Use of WHO Standards

The criteria used to classify medical supplies and services as “adequate” or “inadequate” are not clearly defined. It would strengthen the methodology if the authors referenced established international standards — such as the WHO Hospital Emergency Response Checklist or the Essential Emergency and Critical Care (EECC) framework — to guide and standardize the hospital readiness assessment.

4. Results Section

The sentence “The median ‘maximum age’ of children cared for in the facilities surveyed was 14 years (range: 12–18)” (line 176) requires clarification. It is unclear whether this refers to the maximum age allowed for admission, or the median of the maximum ages reported by each hospital. Both the maximum and median values should be clearly defined and reported consistently.

5. Discussion Section

The discussion section largely restates the results without critically interpreting them in relation to the study’s aim — assessing hospitals' readiness to care for children amid public health emergencies.

Additionally:

The data point that “Fourteen out of 20 hospitals (70%) reported that the wait time in the emergency area was less than one hour” should be discussed more meaningfully. This reported wait time is considerably better than expected in the African context, given known challenges with patient load, staff shortages, and emergency system limitations. The authors should explore possible explanations and discuss this finding within the regional context.

Although the aim mentions readiness for emergencies and disasters, the findings are not adequately discussed within the framework of emergency and disaster preparedness standards. The authors should reflect on how the reported infrastructure, equipment, and services compare to established emergency and disaster readiness benchmarks.

6. Conclusion (in both Abstract and Main Text)

Critical findings such as:

�The necessity of admitting more than one child in a bed.

�The infection risks associated with placing multiple children in one crib

�Frequent interruptions in water supply

should be explicitly highlighted, as these have significant implications for hospital readiness, infection control, and patient safety.

7. Study Limitations

The limitations of the study should be explicitly stated, including:

�The nature of the hospitals surveyed (mostly tertiary, teaching hospitals)

�The sample’s lack of representative for the wider African hospital landscape

�Potential selection bias

Editorial Comments

The aim of the study is unnecessarily repeated between lines 91–96 and again in lines 97–98. This duplication should be removed for clarity.

Key words: can be focused to the research

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Reviewer #1: No

Reviewer #2: Yes: Tigist Bacha

**********

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PLOS Glob Public Health. 2025 Nov 26;5(11):e0005153. doi: 10.1371/journal.pgph.0005153.r002

Author response to Decision Letter 1

24 Aug 2025

Attachment

Submitted filename: Response to Reviewers.docx

pgph.0005153.s015.docx^{(31.5KB, docx)}

PLOS Glob Public Health. doi: 10.1371/journal.pgph.0005153.r003

Decision Letter 1

Vinay Kampalath

23 Sep 2025

PGPH-D-25-01272R1

The Children’s Hospitals in Africa Mapping Project (CHAMP) Survey: Facilities, Equipment, Supplies, Infrastructure, and Capacity to Respond to Emergencies.

PLOS Global Public Health

Dear Dr. Coovadia,

Please submit your revised manuscript by Oct 23 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Vinay Nair Kampalath, MD, MSc, DTM&H

Academic Editor

PLOS Global Public Health

Journal Requirements:

Additional Editor Comments (if provided):

Hi authors, there are some very minor revisions that require attention for editing and language. Please address these and resubmit.

Reviewer #1: Just a few typos: in line 74 there should be two different sentences. Twenty-four sites were recruited. Twenty hospitals from 15 countries completed the survey from 2018 to 2019.

Line 86 should not have a comma after 'where'

Line 100 should not have a comma after 'Tarun'

Line 161 should have a space between Sierra and Leone

Reviewer #2: The revised manuscript can be considered for publication, but it still requires English language editing. I am also uncertain about the reference style (e.g., references 17–23); these may be summarized rather than listed individually. This is a minor issue.

Additionally, in line 198 the authors state that all hospitals have a PICU, yet in the discussion they describe a shortage of pediatric intensive care units. This inconsistency should be corrected.

The conclusion could also be improved: some parts may be moved to the discussion, while the conclusion itself should be concise, summarized, and include the study’s limitations.

Thank you.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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publication criteria?>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Just a few typos: in line 74 there should be two different sentences. Twenty-four sites were recruited. Twenty hospitals from 15 countries completed the survey from 2018 to 2019.

Line 86 should not have a comma after 'where'

Line 100 should not have a comma after 'Tarun'

Line 161 should have a space between Sierra and Leone

Reviewer #2: (No Response)

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Reviewer #1: No

Reviewer #2: Yes: Tigist Bacha

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PLOS Glob Public Health. 2025 Nov 26;5(11):e0005153. doi: 10.1371/journal.pgph.0005153.r004

Author response to Decision Letter 2

2 Oct 2025

Attachment

Submitted filename: Response to Reviewers 2 October 2025 .docx

pgph.0005153.s016.docx^{(26.1KB, docx)}

PLOS Glob Public Health. doi: 10.1371/journal.pgph.0005153.r005

Decision Letter 2

Vinay Kampalath

20 Oct 2025

The Children’s Hospitals in Africa Mapping Project (CHAMP) Survey: Facilities, Equipment, Supplies, Infrastructure, and Capacity to Respond to Emergencies.

PGPH-D-25-01272R2

Dear Prof. Coovadia,

We are pleased to inform you that your manuscript 'The Children’s Hospitals in Africa Mapping Project (CHAMP) Survey: Facilities, Equipment, Supplies, Infrastructure, and Capacity to Respond to Emergencies.' has been provisionally accepted for publication in PLOS Global Public Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact globalpubhealth@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.

Best regards,

Vinay Nair Kampalath, MD, MSc, DTM&H

Academic Editor

PLOS Global Public Health

***********************************************************

Reviewer Comments (if any, and for reference):

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Appendix. Redcap Survey Tool.

(DOCX)

pgph.0005153.s001.docx^{(714KB, docx)}

S1 Table. Nairobi Meeting Attendees.

(DOCX)

pgph.0005153.s002.docx^{(19.8KB, docx)}

S2 Table. Adult ICU Capacity.

(DOCX)

pgph.0005153.s003.docx^{(17.1KB, docx)}

S3 Table. Combined NICU/ PICU Capacity.

(DOCX)

pgph.0005153.s004.docx^{(17.4KB, docx)}

S4 Table. Malnutrition Ward.

(DOCX)

pgph.0005153.s005.docx^{(16.9KB, docx)}

S5 Table. Reasons that prevent adding additional beds.

(DOCX)

pgph.0005153.s006.docx^{(18.1KB, docx)}

S6 Table. Disaster Response.

(DOCX)

pgph.0005153.s007.docx^{(19.4KB, docx)}

S7 Table. Anaesthetic Agents.

(DOCX)

pgph.0005153.s008.docx^{(18.8KB, docx)}

S8 Table. Radiology Services.

(DOCX)

pgph.0005153.s009.docx^{(18.4KB, docx)}

S9 Table. Combined NICU/ PICU Equipment and Supplies.

(DOCX)

pgph.0005153.s010.docx^{(17.6KB, docx)}

S10 Table. Medical Supplies.

(DOCX)

pgph.0005153.s011.docx^{(17.5KB, docx)}

S1 Data. Quantitative Data of the Survey.

(XLSX)

pgph.0005153.s012.xlsx^{(55.5KB, xlsx)}

S2 Data. Qualitative (Free Text) Data of the Survey.

(XLSX)

pgph.0005153.s013.xlsx^{(105.8KB, xlsx)}

Attachment

Submitted filename: Response to Reviewers.docx

pgph.0005153.s015.docx^{(31.5KB, docx)}

Attachment

Submitted filename: Response to Reviewers 2 October 2025 .docx

pgph.0005153.s016.docx^{(26.1KB, docx)}

Data Availability Statement

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PERMALINK

The Children’s Hospitals in Africa Mapping Project (CHAMP) survey: Facilities, equipment, supplies, infrastructure, and capacity to respond to emergencies

Vinayak Bhardwaj

Lawrence R Stanberry

Philip LaRussa

Wilmot James

Maitry Mahida

Aimable Kanyamuhunga

Atnafu Mekonnen Tekleab

Augustine Omoigberale

Crispen Ngwenya

David Musorewegomo

Dipesalema Joel

Ezekiel Mupere

Fidelis Ewenitie Eki-Udoko

Hannah Bousquet

Heloise Buys

Hilda Angela Mujuru

Ike Oluwa Lagunju

Irene Marete

Jethro Zawolo

Jonathan Kaunda Mwansa

Joseph Tawanda Chava

Maima Kawah Baysah

Mildred Anyango Mudany

Nancy Biyeah Yang Ngum

Nellie V T Bell

One Bayani

Pauline Samia

Ruth Nduati

Sam Miti

Schyler Zane Grodman

Thembisile Dintle Mosalakatane

Workeabeba Abebe

Ashraf Coovadia

Roles

Abstract

Introduction

Methods

Survey development

Site selection and survey implementation

Sub-study survey questions

Ethics review

Statistical analysis

Results

Study sites

Hospital characteristics

Table 1. Hospital characteristics.

Inpatient facilities

Table 2. General inpatient wards.

Table 3. Paediatric Intensive Care Unit (PICU).

Table 4. Neonatal Intensive Care Unit (NICU).

Outpatient facilities

Table 5. Paediatric outpatient area.

Table 6. Paediatric emergency room capacity.

Isolation rooms and capacity to cohort patients and surge

Staffing during catastrophic events

Disaster response program

Surgical services

Table 7. Surgical services.

Radiology services and equipment

PICU and NICU equipment and maintenance

Table 8. PICU Equipment.

Table 9. NICU Equipment.

Medical supplies

Infrastructure

Table 10. Infrastructure.

Discussion

Conclusions

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Vinay Kampalath

Roles

Author response to Decision Letter 1

Decision Letter 1

Vinay Kampalath