title: Barriers and facilitators of surgical care in rural Uganda: a mixed methods study.
abstract: Surgical care delivery is poorly understood in resource-limited settings. To effectively move toward universal health coverage, there is a critical need to understand surgical care delivery in developing countries. This study aims to identify the barriers and facilitators of surgical care delivery at Soroti Regional Referral Hospital in Uganda.
  
  
  
  In this mixed methods study, we (1) applied the Surgeons OverSeas' Personnel, Infrastructure, Procedures, Equipment, and Supplies tool to assess surgical capacity; (2) retrospectively reviewed inpatient records; (3) conducted four semistructured focus group discussions with 18 purposively sampled providers involved in perioperative care; and (4) observed the perioperative process of care using a time and motion approach. Descriptive statistics were generated from quantitative data. Qualitative data were thematically analyzed.
  
  
  
  The Personnel, Infrastructure, Procedures, Equipment, and Supplies survey revealed severe deficiencies in workforce (P-score = 14) and infrastructure (I-score = 5). Equipment, supplies, and procedures were generally available. Male and female wards were overbooked 83% and 60% of the time, respectively. Providers identified lack of space, patient overload, and superfluous patients' attendants as barriers to surgical care. Workforce challenges were tackled using teamwork and task sharing. Inadequate equipment and processes were addressed using improvisations. All observed subjects (n = 31) received interventions. The median decision-to-intervention time was 2.5 h (Interquartile Range [IQR], 0.4, 21.4). However, 48% of subjects experienced delays. Median decision-to-intervention delay was 14.8 h (IQR, 0.9, 26.6).
  
  
  
  Despite severe workforce and physical infrastructural deficiencies at Soroti Regional Referral Hospital, providers are adjusting and innovating to deliver surgical care.
authors.affiliation: Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, San Francisco, California. Electronic address: obieze.nwanna.n@gmail.com.
authors.forename: Obieze C
authors.initials: OC
authors.lastname: Nwanna-Nzewunwa
authors.affiliation: Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda.
authors.forename: Mary-Margaret
authors.initials: MM
authors.lastname: Ajiko
authors.affiliation: Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda.
authors.forename: Fred
authors.initials: F
authors.lastname: Kirya
authors.affiliation: Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda.
authors.forename: Joseph
authors.initials: J
authors.lastname: Epodoi
authors.affiliation: Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda.
authors.forename: Fiona
authors.initials: F
authors.lastname: Kabagenyi
authors.affiliation: Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Batibwe
authors.affiliation: Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, San Francisco, California.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Feldhaus
authors.affiliation: Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, San Francisco, California.
authors.forename: Catherine
authors.initials: C
authors.lastname: Juillard
authors.affiliation: Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, San Francisco, California.
authors.forename: Rochelle
authors.initials: R
authors.lastname: Dicker
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003906:Developing Countries; D005260:Female; D017144:Focus Groups; D019538:Health Care Surveys; D006295:Health Resources / Q000458:organization & administration* / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000458:organization & administration* / Q000706:statistics & numerical data; D006742:Hospital Bed Capacity / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000592:standards / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000592:standards / Q000706:statistics & numerical data*; D014454:Uganda; D055815:Young Adult
keywords: Capacity assessment; Global surgery; Low-income country; Quality; Surgical capacity; Uganda