Measuring health facility readiness for obstetric fistula surgery and care in Busoga sub-region, eastern Uganda

Abstract

Background: Obstetric fistula (OF) remains a devastating injury in Uganda, with an estimated 90% of needs unmet. Service delivery through temporary repair camps, rather than integrated routine surgical programs, limits the health system's capacity to address backlogs and ensure quality. A critical initial step for transitioning to integrated routine OF care is assessing facility readiness; however, no standardized framework exists in Uganda for this purpose. Objective: To develop a consensus-based facility readiness scoring criteria and framework for obstetric fistula surgery and care and apply that criteria to assess the readiness of six hospitals in eastern Uganda. Materials and Methods: This study utilized a two-phase approach. Phase I involved developing a consensus-based scoring framework adapted from WHO and UNFPA guidelines. Phase II conducted a cross-sectional readiness assessment of six hospitals between May and July 2024. Readiness was evaluated across seven weighted domains: human resources, infrastructure, equipment and supplies, supportive services, clinical protocols, monitoring systems, and management accountability. Results: A 23-expert panel validated the seven-domain framework in April 2024. Readiness scores across the six facilities ranged from 38% to 84%. Only one facility met the predefined readiness threshold (≥ 80%). Two hospitals demonstrated partial readiness (65–69%), while three were classified as not ready. Human resources were the principal constraint, with only one hospital employing a resident fistula surgeon. While basic infrastructure including water, electricity, and operating theatres was largely adequate, fistula-specific capacity was consistently limited. Most facilities lacked complete surgical instrument sets, specialized equipment, monitoring systems, and standardized clinical protocols. Conclusion: The developed consensus-based readiness criteria offer a practical tool for identifying capacity gaps and supporting the decentralization of OF services in low-resource settings. Most hospitals in this region currently lack the structural readiness required for routine fistula surgery, primarily due to significant deficits in specialized human resources, fistula-specific equipment, and clinical governance.