Pediatric Surgery Collaboration in Uganda, the Benefits of Long-Term Partnerships at Regional Referral Hospitals

Greg Klazura^1*, Peter Kayima², Martin Situma³, Edwin Musinguzi⁴, Robert Mugarura⁵, James Nyonyintono⁶, Ava Yap^7, James Cope⁸, Richard Akello⁹, Emmanuel Kiwanuka⁹, Moses Odonkara⁹, Chelsea Okellowange⁹, Jennifer Adongpiny⁹, Daniels Lakwanyero⁹, Patricia Atim⁹, Aber Patience Cadrine⁹, Joshua Olara⁹, Amulya Boppana¹, Ruth Laverde⁷, Sergio d’Agostino¹⁰, Bruno Cigliano¹⁰, Doruk Ozgediz⁷, Thomas Sims¹, Phyllis Kisa²

¹Department of Surgery, University of Illinois Hospital and Health Sciences, 840 South Wood Street #406, Chicago, Illinois, 60612, United States of America
²Mulago National Referral Hospital, Haji Musa Kasule Road, Kampala, Uganda
³Mbarara Regional Referral Hospital, Mbarara Rd, Mbarara, Uganda
⁴Fort Portal Regional Referral Hospital, Mugurusi Rd, Fort Portal, Uganda
⁵Kabale Regional Referral Hospital, Corryndon Road, Kabale, Uganda
⁶Kiwoko Hospital, Nakaseke District, Uganda
⁷Center for Health Equity in Surgery and Anesthesia, University of California San Francisco Third Floor, 550 16th Street, San Francisco, California, 94158, United States of America
⁸Faculty of Medicine, University of New South Wales, Sydney, New South Wales, 2052, Australia
⁹St. Mary’s Lacor Hospital, Gulu, Uganda
¹⁰Surgery for Children, Via Lago di Pusiano, 1, Vicenza, Italy

*Corresponding author: Greg Klazura, Department of Surgery, University of Illinois Hospital and Health Sciences, 840 South Wood Street #406, Chicago, Illinois, 60612, United States of America; Email: greg.klazura@gmail.com

Citation: Klazura G, et al. Pediatric Surgery Collaboration in Uganda, the Benefits of Long-Term Partnerships at Regional Referral Hospitals. J Pediatric Adv Res. 2025;4(2):1-9.

Copyright^© 2025 by Klazura G, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Table 1: Common currency creation.

Results

Over all four sites, 8,615 admissions and 5,457 surgical cases were included. In terms of admissions, Lacor patients were significantly younger (p<.001), had a longer length of stay (p<.001) and were less likely to be referred (p<.001) (Table 2). There was no difference in the percentage of admissions that were surgical emergencies. In terms of surgical cases, Lacor had the highest case volume and were more likely to operate on younger patients, including infants (p<.001) (Table 3). Pediatric surgical cases at Lacor were also more likely to be performed under general anesthesia compared to other sites (p<.001). In 2018, Lacor surgeons performed 955 cases on patients < 18 years old while Fort Portal surgeons performed 477, Kiwoko surgeons performed 393 and Kabale surgeons performed 153 (Fig. 1).

The differences in case volume between sites led to a substantial difference in long term monetary health benefit (Fig. 2). Across all methods of economic impact estimation, Lacor had the greatest economic impact due to pediatric surgery (Atlas, USD10,485,650; VSLY, USD24,808,320; and PPP, USD29,621,961), with Kabale having the least impact (Atlas, USD1,601,890; VSLY, USD1,341,579; and PPP, USD567,041).

Table 2: Admissions book comparing Lacor to the other three sites.

Table 3: Surgery Logbook comparing St. Mary’s Hospital Lacor to the other three sites.

Figure 1: Surgical volume and age graph. These two bar graphs demonstrate the OR volume and age breakdown of patients that received surgery from a general surgeon over one year (2018). General surgeons performed 967 cases on patients <18 years old in Lacor while 153 cases were performed in Kabale in 2018. Legend: FPRRH, Fort Portal Regional Referral Hospital; KRRH: Kabale Regional Referral Hospital; OR: Operating Room.

Figure 2: Economic impact of pediatric surgery in one year (2018). This bar graph demonstrates the economic impact of one year of pediatric surgery at each site using three different economic models. Legend: PPP: Purchasing Power Parity; USD: United States Dollar; VSLY: Value of a Statistical Life Year.

Discussion

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 one to 3.5 million people.

Table 4: Surgery Logbook comparing St. Mary’s Hospital Lacor to the other three sites. Catchment area, operating rooms and general surgeons at each site.

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.

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 A 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, as well increased resourcing with the highest number of operating rooms and general surgeons.

Since 2006, 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. Three Ugandan doctors subsequently trained and received qualifications as paediatric surgeons: Dr. Peter Kayima, Dr. Phyllis Kisa and Dr. Charles Odongo. 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. Over 16 surgical camps, they have seen over 1500 patients over 20 years, with roughly 750 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 in 2006 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 4). 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.

Operating rooms require surgeons, nurses and anesthesiologists 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 4). In addition, St. Mary’s Lacor has more surgeons: four general surgeons, one oral and maxillofacial surgeon and two orthopedic 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 Lacor 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 equals 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]. 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 in order to support the important work that regional referral hospitals and general surgeons perform [18]. 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. Future research is also warranted, particularly examining the benefits for pediatric patients receiving care locally against referral to larger centers, as well as the long-term results of correction of complex congenital malformations at each of the included study sites.

Conclusion

Rural general surgeons in Uganda are responsible for treating much of the pediatric surgical disease in Uganda. To support their efforts and meet the burden of disease, stakeholders should make investments in surgical infrastructure, workforce and education. As stakeholders aim to strategically direct resources to scale healthcare infrastructure and surgical capacity they should explore and support collaborations with committed partners because long-term partnerships provide an environment for investments in health and surgery to grow and make an impact.

Conflict of Interests

The authors declare that they have no conflicts of interest.

Funding

This work was supported by a Fulbright Fogarty Fellowship (GHES NIH FIC D43 TW010540).

Author Contributions

Study conception and design: GK, PK, MS, DO, PK. Data acquisition: GK, PK, RA, EK, MO, CO, JA, DL, PA, APC, JO. Analysis and data interpretation: GK, PK, AY, AB. Drafting of the manuscript: GK, PK, RL. Critical revision: GK, PK, EM, RM, JN, JC, RC, RL, SD, BC, DO, TS, PK. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Institutional Review Board (IRB) exemption was obtained from the University of Illinois at Chicago (Protocol #2021-0600) and IRB approval was obtained from the University of California San Francisco (IRB #21-34335) and Makerere University (MAKSHSREC-2021-142). The Ugandan National Committee of Science and Technology also provided approval (Ref. #HS1895ES) to collect data on pediatric surgery patients and operative volume at St. Mary’s Hospital Lacor.

Informed Consent Statement

Not applicable.

Data Availability Statement

The datasets generated and/or analysed during the current study are not publicly available due to concerns for individual patient privacy but are available from the corresponding author on reasonable request.

Acknowledgments

Not applicable.

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