Perceptions of facilitators, barriers and adaptations for provision of obstetric fistula surgery and care: a qualitative descriptive study of service providers in selected hospitals in Busoga sub-region, eastern Uganda

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Introduction: Obstetric fistula is a devastating childbirth injury common in low-resource settings, with many women failing to access surgical repair due to health system challenges. However, limited evidence exists on the health system factors shaping the provision of fistula care and surgery. The study aimed to explore facilitators, barriers encountered, and adaptation mechanisms employed by healthcare providers in the provision of fistula surgery and care. Methods: = 8) with purposively selected national fistula experts/surgeons, policy makers and implementing partners. Data were audio-recorded, transcribed verbatim and analyzed using a deductive thematic analysis, guided by the World Health Organization (WHO) health system blocks framework. Results: Seven themes emerged from the findings including: 1) human resources, 2) equipment and supplies, 3) infrastructure, 4) financial resources, 5) access to services, 6) adaptation mechanisms, and 7) recommendations for improved provision of obstetric surgery and care. Facilitators to provision of fistula surgery and care included government coordination and stewardship, availability of trained specialists during fistula camps, donor-supported equipment and supplies, community mobilization, and financial support to patients. However, significant barriers including inadequate and poorly compensated staffing, high staff turnover, inconsistent supplies and equipment, limited ward space leading to overcrowding, and an overreliance on external donor funding constrained routine service provision. Access barriers included stigma, limited awareness and high transport costs involved in seeking care. However, the hospitals have developed adaptation mechanisms such as flexible scheduling and improvising spaces for instance use of tents to cope with bed and space shortages. Participants recommended improving the provision of care through better preparation and staffing of hospitals. Conclusion: While fistula camps provide short-term access to life changing fistula surgery, they reflect underlying health system challenges. Strengthening routine fistula services by addressing systemic, financial, and sociocultural barriers is critical to ensure equitable and sustainable fistula care in Uganda.

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