Surgical Infrastructure and Workforce Readiness in Rwanda's District and Level 2 Teaching Hospitals: A Nationwide Facility‐Based Survey

BACKGROUND: Access to safe, timely, and affordable surgical care remains a challenge in low- and middle-income countries (LMICs), where deficits in infrastructure and workforce are most acute at the district hospital level. From 2018 to 2024, Rwanda implemented its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP) and prioritized decentralized surgical care. We aimed to conduct a post-implementation national assessment of surgical infrastructure, workforce, and service delivery at Rwanda's district and level 2 teaching (L2TH) hospitals. METHODS: We conducted a nationwide cross-sectional survey of 43 hospitals, comprising all 34 district hospitals, and 9 L2TH in Rwanda from May-June 2025, using the WHO Situational Analysis Tool for Emergency and Essential Surgical Care (SAT-EESC). Five domain-specific informants per facility provided infrastructure, workforce, and service delivery data, complemented by facility walk-throughs and a review of operating room registers. In addition to descriptive data analysis, we compared rural and urban hospitals and mapped workforce distribution. RESULTS: All facilities had at least one functional operating room. Most facilities reported continuous electricity and running water, and oxygen cylinders were available at all times in 90.7% of facilities. Blood banks and oxygen concentrators were the least consistently available, reported as available at all times in 32.6% and 58.1% of facilities, respectively. The median facility-level surgeon, anesthesiologist, and obstetrician density was 0.71 per 100,000 population, and 14 hospitals had no specialist SAO cadre. Non-specialist cadres were widely available, with a median non-specialist surgical workforce density of 6.76 per 100,000 population. No statistically significant urban-rural workforce differences were observed, although rural facilities were significantly farther from next-level referral facilities. CONCLUSION: Rwanda's district and level 2 teaching hospitals demonstrate high infrastructure readiness. However, gaps persist in the distribution of the specialist workforce, diagnostics, and advanced surgical care capacity. The findings also highlight the importance of non-specialist cadres in sustaining district-level surgical service delivery.