Different health centers operate at different capacities for several reasons. Catchment area, operating room space, workforce size, patient demographics, number of hospital beds, and funding mechanisms, all can affect the number of cases performed (Table 4). These four health centers: Fort Portal Regional Referral Hospital, Kabale Regional Referral Hospital, Kiwoko Mission Hospital and St. Mary’s Lacor Hospital all function as regional referral hospitals with catchment areas ranging from 630,000 to 3.5 million people.
All four hospitals also have experienced general surgeons and at least two operating rooms but no full-time, board-certified pediatric surgeon on staff. We discuss the implications of the differences in the data we collected: patient characteristics, operative volume, and economic impact. Finally, we considered ways to increase pediatric surgical capacity in Uganda given our findings.
Table 4
Catchment area and Number of Operating Rooms
Hospital | Catchment Area |
Fort Portal | 3,500,000 |
Kabale | 1,200,000 |
Kiwoko | 1,000,000 |
St. Mary’s Lacor | 1,213,700 |
St. Mary’s Hospital Lacor annual report and Kiwoko’s website provided their catchment area while the head of the surgery department provided catchment size at Fort Portal and Kabale.
Pediatric patients at Lacor were younger, had a longer LOS, and were referred less. These findings suggest that surgeons at Lacor were performing more complex procedures. In pediatric surgery, younger patients are often sicker with more complex disease. Younger patients, with longer hospital stays, and the use of general anesthesia also suggest more complex patients and procedures. Review of the operating room diagnoses corroborates these findings. Appendix I lists all diagnoses operated on at each site in 2018. St. Mary’s Lacor operated on more children with complex congenital anomalies such as anorectal malformations, Hirschsprung Disease, urogenital malformations, and atresia’s.
St. Mary’s Lacor, however, was not only performing more complex surgery, but they were also performing more pediatric surgery overall. In 2018, St. Mary’s Lacor performed 955 pediatric surgical procedures, roughly six times more than KRRH.
Like the other three hospitals, St. Mary’s Lacor does not have a board certified pediatric surgeon. Yet St. Mary’s Lacor performed far more complex pediatric surgery. Pediatric surgery is a nuanced surgical subspecialty. Children and families can suffer immensely when unqualified providers attempt to repair complex congenital anomalies. Rural general surgeons may need to emergently divert babies and children with bowel obstructions, but they should not attempt to repair anorectal malformations or perform pull-through procedures for Hirschsprung Disease. So why are general surgeons at Lacor performing more complex cases? The answer is not medical malpractice but rather St. Mary’s Lacor benefits from longitudinal mentorship and support with Ugandan and international collaborators.
For over 15 years, pediatric surgeon Dr. Martin Situma from Mbarara University in southwestern Uganda and two pediatric surgeons, one from the University of Naples in Italy and the other from San Bortolo Hospital Vicenza, both also members of Surgery for Children (SFC), a non-profit Italian association, have traveled to Lacor Hospital, performed surgery, and mentored local surgeons and staff there. St. Mary's Lacor general surgeons and pediatric surgeons from Mbarara and Italy performed many cases side-by-side. The SFC team consisted of 15 to 20 pediatric surgeons, anesthetists and nurses. They saw 1350 patients over 15 years, with roughly 700 undergoing major surgery (anorectal malformations, Hirschsprung's disease, urogenital malformations and disorders of sexual development). The treatment opportunities offered by SFC also exposed many “hidden” patients. This mentorship that started over 15 years ago still continues.
Although all four sites participated in the PESC, St. Mary’s Lacor was the only site that participated twice. Course participants said that they wanted hands-on experience after PESC in order to build on the lessons they learned (6). Long-term relationships with academic partners in Italy and Mbarara provided this sustained opportunity for further in-person training at Lacor.
Long-term partnerships alone, however, likely cannot explain the higher surgical volume at St. Mary’s Lacor. Despite a smaller catchment area than the other three hospitals, St. Mary’s Lacor also performed considerably more surgery than the other three hospitals.
No single reason explains the case volume at Lacor but there are several key differences between St. Mary’s and the other sites. Lacor has more operating rooms, eight to be exact, four times more than Kiwoko (Table 5). Previous work has shown that additional operating rooms are a cost effective health intervention. More specifically, the addition of a pediatric specific operating room averted death and disability in a more cost effective manner than other more typical global health interventions. In fact, installing a dedicated pediatric Operating Room in Uganda has an incremental cost effectiveness ratio (ICER) of $37.25 per DALY while antiretroviral therapy for human immunodeficiency virus has an ICER of $350 to $1494 per DALY averted (16). Quite ostensibly, without an operating room it is difficult to perform surgery and the addition of functioning operating rooms is a cost effective mechanism of increasing surgical capacity.
Table 5
Number if operating rooms at each hospital in 2018
Hospital | Number of Operating Rooms |
Kiwoko | 2 |
Kabale | 3 |
Fort Portal | 4 |
St. Mary’s Lacor | 7 |
Operating room counts were obtained from staff surgeons. We included Obstetric operating rooms but did not include minor procedure rooms.
Operating rooms require surgeons, nurses, and anesthesiologists in order to deliver care. Previous work has also shown that the surgical workforce is the most important driver of increasing surgical capacity in Uganda (17). Although none of the sites had a board certified pediatric surgeon on staff, Lacor’s operating rooms have the ancillary staff: a triage and postoperative care unit to operate 24 hours a day, seven days a week. This same capacity is not shared at the other sites (Table 6). In addition, St. Mary’s Lacor has more surgeons: four general surgeons, one oral and maxillofacial surgeon, and two orthopedic surgeons.
Table 6
Number of general surgeons at each hospital in 2018
Hospital | Number of General Surgeons |
Kabale | 1 |
Kiwoko | 2 |
Fort Portal | 2 |
St. Mary’s Lacor | 4 |
Operating room counts were obtained from staff surgeons.
Despite a smaller catchment area, St. Mary’s Lacor performed more pediatric surgery than three other regional referral hospitals. There is no evidence to suggest that St. Mary’s was performing unsafe surgery. There is also no evidence to suggest that general surgeons at Fort Portal, Kabale, and Kiwoko were not providing as much surgery as they possibly could given their resources. Rather, what we see is that more operating space, and a greater surgical workforce increases surgical capacity.
More operating rooms and more surgeons = more surgery, this is somewhat self-evident. The implications of our findings, however, are more than just intuitive. General surgeons perform most of the pediatric surgery in Uganda (5). Developing surgical infrastructure to support their work is no small feat because despite the heroic efforts from general and pediatric surgeons less than 4% of the total burden of pediatric surgical disease is treated in Uganda (18). In order to help meet the burden of disease, long term collaboration with international partners has already proven to be beneficial and not just in Lacor. Collaborative efforts among pediatric surgical stakeholders in Uganda have created a pediatric surgery fellowship in both Kampala and Mbarara, installed pediatric operating rooms in Kampala and Mbarara, and performed sustained mentorship in pediatric surgery in Soroti and Lacor (19).
To meet the burden of pediatric surgical disease in Uganda continued collaboration with partners who are committed to long term investment is vital. These collaborations have the ability to upscale the amount of surgery provided and make a tremendous impact on the health and wealth of Uganda (5). Given the burden of pediatric surgical disease nationwide and the economic impact of providing pediatric surgery, hiring a full time pediatric surgeon should perhaps be given consideration in every referral hospital. Nevertheless, Lacor’s long term partnerships and concomitant investments from Ugandan and international stakeholders have made pediatric surgery there possible. This holds valuable lessons.
Ugandan surgeons are more than capable of caring for even the most complex of patients, such as pediatric congenital anomalies. Nevertheless, resources and specialists are limited. As a result, children suffer and greater investment in surgery is absolutely needed (18) in order to support the important work that regional referral hospitals and general surgeons perform. There is no single strategy to increase capacity. Scaling surgical infrastructure, increasing the surgical workforce, and providing surgical education are all vital components of increased capacity. Longitudinal collaboration with academic partners and financial support from both Ugandan and international stakeholders has data-driven precedent. These partnerships increase case volume and subsequent economic impact. High-yield partnerships are not unique to Uganda (20) and they should be given special consideration as they help create the appropriate environment for life-saving investments in pediatric surgery to grow.